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Proof (Pictures - included) Acne Scar Treatments, Medical Case Studies, Acne Scar Successful Treatments

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I posted this 2- years ago when I was asked for proof of successful treatments "pics", or has anyone had success. This is now included in my DIY Guide to Acid peels (Linked off the FAQ - top of the acne scar sub - first post - Under Peels).

This post was made so you can see the treatments we offer do successfully work even if people do not post "pics". Acid peels are very successful as a alternative to laser at resurfacing the skin (without the side effects). If your doing DIY it takes many treatments over time ) 3 months it takes collagen to develop, or your Dr can do a "deep" sedated TCA or Penol peel to get under the scars. Microneedling without TCA is not effective they work synergistically together over time. This may be subsituated with RF Microneedling (Infini) if you have the proper scars and $$$$.  Also be aware the above study exact method might not work for you or your individual case, this is why the FAQ was made (many studies like this hide secrets Dr's do for treatment or do things unsafe for home DIY. Do not attempt this without reading the FAQ and Acid Peel Guide. AS always a doctor can treat with much better results and quicker outcomes for your personalized scar types. 

https://www.acne.org/messageboard/topic/361029-official-acne-scar-solutions-qa-faq-read-before-posting/

( See the Success Story Threads There)


Point anyone who wants proof to this post ("Pics" below).

TCA, Microneedling, Subcision w/ Filler give the best results for Acne Scars!

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The science behind acne scarringAcneScars2.jpg

The intensity and duration of the inflammatory reaction in acne causes dermal damage and alteration of the sebaceous gland structure leading to atrophic scar formation, but not all patients are affected equally.
Jul 16, 2018
 
The inflammatory response in papules of patients with acne prone to scarring can last more than three weeks and is characterized by a marked infiltration of B cells, a study published in the British Journal of Dermatology has found,  whereas the immune response in papules of patients with acne not prone to scarring resolves much more rapidly.

The researchers suggested that the intensity and duration of this inflammatory reaction causes dermal damage and alteration of the sebaceous gland structure leading to atrophic scar
formation.

While the pathogenesis of atrophic acne scarring is not completely understood, severity and duration of inflammation is considered likely to play a role.

One previous study analyzed the immune response in acne scarring by comparing acne lesions in scar-prone and non-scar-prone patients,  and found that in the first seven days the inflammatory reaction around the pilosebaceous follicle was stronger and lasted longer in patients with scarring.

THE STUDY
For this current study, researchers wanted to look at the immune response over a longer period. They analyzed the pathophysiologic mechanisms occurring in scar prone and non-scar prone acne patients in lesions of three weeks by performing large scale gene expression profiling to identify molecular and cellular pathways that may account for the predisposition to scar formation. Then then used immunohistochemistry techniques to confirm their results.

Nineteen patients with moderate inflammatory acne as defined by the ECLA score, were enrolled in the study with 10 prone to scarring and nine were not. Biopsies of non-lesional skin and of inflammatory lesions less than 48 hours old were taken from their backs, and further lesions less than 48 hours old were identified for follow up 21 days later. Biopsies of these “evolved lesions” were taken at 21 days.

Biopsies were also from ten healthy volunteers to provide a comparison of healthy skin, and skin samples were obtained from five healthy people undergoing plastic surgery for gene expression profiling of human sebaceous glands and epidermis.

Gene expression and immunohistochemistry analyses showed a very similar immune response in 48 hours-old papules in scar prone and non-scar prone patients with acne, characterized by elevated numbers of T cells, neutrophils and macrophages.

However, when the three-week old papules were examined, it was clear that the immune response persisted only in scar prone patients, and an infiltrate of B cells was evident.

Down-modulation of sebaceous gland markers related to lipid metabolism was observed in 48 hours-old papules in non-scar prone patients, but this had normalized after three weeks. In contrast, there was a drastic reduction of these markers in scar prone patients which persisted at three weeks, suggesting “an irreversible destruction of sebaceous gland structures after inflammatory remodelling in scar-prone acne patients”, the researchers said.

“We demonstrated that the inflammatory response is still present in 21-days lesions in acne patients prone to scarring compared to those who do not develop scars, suggesting a difference in the acne lesion life-cycle between the two populations,” Dr Johannes Josef Voegel said.

“Inflammatory lesions persist after three weeks only in patient with scars, with an exacerbation of number and modulation of genes involved in the immune response. This was in line with higher influx of T cells and macrophages observed by immunohistochemistry.”

A lack of neutrophils in the three-week papules of scar prone patients showed the persistence of an adaptive immune response, he added, suggesting “either a non-elimination of the trigger factor and/or an absence of inflammation resolution signals or inappropriate immune response.” However, the infiltrate of mature B cells and strong expression of several immunoglobulin genes was unexpected, he said.

B CELLS
B cells have diverse functions in the adaptive immune system and have been observed in chronic inflammatory skin conditions such as atopic dermatitis. They may contribute to the skin-specific immune response by producing local antibodies and exhibiting either pro-inflammatory or anti-inflammatory activities, Dr Voegel said. “The influx of mature B cells occurs late in acne lesion cycle and only in long-lasting lesions of patients with scarring. It is currently unclear whether the flux of B cells in older acne lesions contributes to sustaining the immune response or to dampening the inflammation via anti-inflammatory mechanisms.”

There is growing evidence suggesting that B cells might be as important as T cells in the pathogenesis of several inflammatory skin diseases, including autoimmune blistering disorders, psoriasis and atopic dermatitis.

“In late-stage acne lesions, B cells might fulfil both antibody-dependent and independent roles in the maintenance of skin immunity and inflammation. Additionally, B cells by producing cytokines regulate collagen synthesis by fibroblasts and thus could contribute to the scarring process,” he suggested.

GENE EXPRESSION PROFILE
The difference in the gene expression profile of 48 hour and 21-day lesions in scar prone patients indicated profound remodelling of the skin, the researchers suggested. In particular, the dramatic down-modulation of a lipid-associated gene set, which is preferentially expressed in human sebaceous glands, supports the disappearance of sebaceous glands in atrophic acne scars.

They speculated that dermal thinning is caused by a loss of pilosebaceous units and insufficient replacement of dermal matrix. Disappearance of sebaceous glands has also been noted in viral infection of the epidermis by herpes zoster (varicella) which has a potential to scar.

“By extension, in the acne population prone to scarring, the destruction of sebaceous glands by an exacerbated inflammatory response can result in atrophic scar formation. The destruction of the entire pilo-sebaceous unit causes a loss of dermal continuity, which is later filled with granulation tissue. At the end of the healing process the granulation tissue shrinks, resulting in atrophic scar formation,” they proposed.

 

References: 

Carlavan I, Bertino B, Rivier M,  Martel P, Bourdes V, Motte M, Déret S, Reiniche P, Menigot C, Khammari A, Dreno B, Fogel P, Voegel JJ. Atrophic scar formation in acne patients involves long‐acting immune responses with plasma cells and alteration of sebaceous glands. British Journal of Dermatology 2018 doi: 10.1111/bjd.16680

  Holland DB, Jeremy AHT, Roberts SG, et al. Clinical and Laboratory Investigations Inflammation in acne scarring:  A comparison of the responses in lesions from patients prone and not prone to scar. Br J Dermatol 2004; 150:72–81.

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Combination Therapy in the Management of Atrophic Acne Scars

. 2014 Jan-Mar; 7(1): 18–23.

INTRODUCTION

Acne is prevalent in over 90% adolescents and it persists into adulthood in approximately 12%-14% of cases with psychological and social implications.[,,] In some patients with acne, the inflammatory response results in permanent, disfiguring scars from either increased tissue formation or due to loss or damage of tissue. Hypertrophic scars and keloids are examples of scars that result from increased tissue formation. Scars with loss or damage of tissue can be classified into icepick, rolling and boxcar scars.[] There is no standard treatment option for the treatment of acne scars. Medical management of atrophic scars can be done by using topical retinoids. Surgical management can be done using punch excision, elliptical excision, punch elevation, skin grafting and subcision depending on the type of scar. Procedural management includes microdermabrasion, chemical peels, percutaneous collagen induction by microneedling and dermabrasion. Tissue augmentation can be done using xenografts, autografts and homografts. Various ablative and non-ablative lasers and light energies are also available for treatment of atrophic acne scars.[] Out of these multiple treatment options, treatment has to be tailored to patient's needs, tolerance, and goals along with the physician's assessment, skills and expectation. Patient should be counselled that the ultimate goal of any intervention is to improve the scars and no currently available treatment will attain total cure or perfection.

In 1995, Orentreich and Orentreich described subcision as a method of subcuticular undermining of scars using a tri-beveled hypodermic needle. This results in lifting the scar by releasing the papillary dermis from the binding connections of the deeper tissues and by the formation of connective tissue that results from the course of normal wound healing.[] It is mainly used for the treatment of rolling type of atrophic scars.[]

The mechanism hypothesised for action of percutaneous collagen induction using dermaroller is that it creates thousands of microclefts through the epidermis into the papillary dermis. These wounds create a confluent zone of superficial injury which initiates the normal process of wound healing[] with release of several growth factors. This stimulates the migration and proliferation of fibroblasts resulting in collagen deposition[] which continues for months after the injury.[] Another hypotheses states that on penetration of skin with the microneedles, the cells react with a demarcation current which in addition to the needles own electrical potential results in release of various growth factors. This cuts short the healing process and stimulates the healing phase.[] Dermaroller also opens pores in upper layers of epidermis and allows creams to be absorbed more effectively by the skin.

Fifteen percent tricholoroacetic acid (TCA) peel is superficial peeling agent. It causes exfoliation, improves the skin texture and induces collagen synthesis.[]

The aim of our study was assessment of combination therapy using subcision, dermaroller and 15% TCA peel for the management of atrophic acne scars. The rationale for combining these three minimally invasive procedures was their additive action on acne scars. Subcision releases the scars from the underlying adhesions which should be the first step for any treatment for acne scars. Microneedling with dermaroller causes collagen induction along with enhancing absorption of tretinoin cream. Fifteen percent TCA peel causes improvement in skin texture as well as collagen induction. Hence by combining these three minimally invasive modalities one can release the scars, enhance collagen induction, increased penetration of topical agents and resurface the skin.

 

MATERIALS AND METHODS

Fifty patients with atrophic acne scars were enrolled in this study. Exclusion criteria were patients with active acne, active herpes labialis, patients on systemic retinoids, evidence or history of keloid scars, pregnancy or lactation, history of any facial surgery or procedure for scars and patients with unrealistic expectations. All the patients were counselled for surgical intervention and written informed consent was taken. The atrophic acne scars were graded by a single non-treating physician using Goodman and Baron Qualitative scar grading system [Table 1].[]

Table 1
Goodman and Baron Qualitative scar grading system

Patient's skin was primed using topical tretinoin cream 0.05% at night along with sunscreen with a minimum SPF of 30 during the day for 2 weeks prior to starting the treatment. At the start of treatment, subcision was performed only once using a 24G needle. One day after the subcision, patient was called for the first sitting of microneedling with dermaroller containing 192 needles of needle size 1.5 mm. Eutectic mixture of lignocaine 2% and prilocaine 2% cream was applied under occlusion for 1 hour to the affected areas which was removed using gauze. Thereafter topical tretinoin cream 0.05% was applied to the affected area. Treatment was performed by rolling the dermaroller in vertical, horizontal and diagonal directions in the affected area until appearance of uniform fine pinpoint bleeding. Then the area was wiped with saline soaked gauze and tretinoin cream 0.05% was applied and washed off after 30 minutes. Two weeks after dermaroller, patient was called for 15% TCA peel. Whole face was cleansed using spirit and degreased using acetone. Fifteen percent TCA peel was applied with cotton tipped applicator on full face. Appearance of speckled white frosting was the end point of treatment with peel. After using dermaroller and 15% TCA peel, patient was instructed to apply sunscreen in the morning and mometasone furoate cream 0.1% twice daily for 5 days after which sunscreen was continued in the morning with tretinoin cream 0.05% applied at night time. Patient was asked to discontinue topical tretinoin cream application 2 days prior to TCA peel. Thereafter, dermaroller and 15% TCA peel were repeated alternately after every 2 weeks for six sessions of each and this was taken as the end point of our study. In some patients who developed inflammatory lesions of acne during treatment, capsule doxycycline or topical clindamycin cream 1% was given as and when required. Any adverse effects and interference in daily activities post-treatment were noted. Patients were evaluated for results 1 month after the last procedure was performed. Post-treatment scars were graded again by the same physician using Goodman and Baron Scale. Patient graded their response to treatment as poor, good, very good or excellent with 0-24%, 25-49%, 50-74% and 75-100% improvement, respectively, in their acne scars. The patients were followed up for 1 year at two monthly intervals to observe the sustenance of improvement in scars. Digital colour facial photographs were taken before treatment, during each visit of treatment, at 1 month after the last procedure and at 2 monthly intervals for 1 year after the last procedure. Patients were instructed to continue application of topical tretinoin cream 0.05% for 1 year after the last procedure.

Statistical analysis

Descriptive statistics such as mean and standard deviation are calculated. Data is presented in frequencies and their respective percentages. Data was entered and analysed using SPSS version 18.

 

RESULTS

Out of 50 patients, 49 patients completed the treatment. Out of 49 patients 2 patients were treated with capsule doxycycline during the treatment protocol due to active acne eruptions. Out of 49 patients there were 30 females and 19 males with age group between 18-39 years with mean age of 25.6 ± 5.2 yrs. 9 patients (18.4%) had Type III Fitzpatrick skin type, 32 (65.3%) type IV and 8 (16.3%) patients had type V Fitzpatrick skin type. Pre treatment melasma was present in 3 (6%) patients.

Out of 49 patients who completed the treatment, 16 patients had Grade 4, 22 patients had Grade 3 and 11 patients had Grade 2 scars before treatment. The physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system is summarised in Table 2. In patients with Grade 4 scars, 10 patients (62.5%) showed improvement by 2 grades i.e., their scars improved from Grade 4 to Grade 2 of Goodman Baron Scale [Figure [Figure1a1a and andb].b]. Six patients (37.5%) with Grade 4 scars showed improvement by 1 grade [Figure [Figure2a2a and andb]b] with scars being obvious at social distances of 50 cm or greater. In 22 patients with Grade 3 scars, 5 patients (22.7%) showed improvement by 3 grades i.e., they were left with no scars at all [Figure [Figure3a3a and andb],b], Two patients (9.1%) improved by 2 grades and as per Grade 1 they were left with only hyper-pigmented flat marks [Figure [Figure4a4a and andb]b] and 15 patients (68.2%) showed improvement by 1 grade by moving to Grade 2 [Figure [Figure5a5a and andb]b] as per Grade 2 their scars were not obvious at social distances of 50cm or greater. All 11 patients (100%) who had Grade 2 scars before treatment showed improvement by 2 grades in their scars and were left with no scars [Figures [Figures6a6ab and and7a7ab]. Hence all 49 patients (100%) had improvement in their scars by some grade with no failure rate. In patients with Grade 4 scars [Table 3], 12 patients (75%) graded their response to treatment as very good with 50-74% improvement in their acne scars after treatment and 4 patients (25%) had good improvement in their scars with 25-29% improvement. In patients with Grade 3 scars, 8 patients (36.4%) graded their response to treatment as excellent with 75-100% improvement in their scars and 14 patients (63.6%) reported the response as very good with improvement between 50 and 74%. All 11 patients (100%) with Grade 2 scars graded their response after treatment as excellent with improvement between 75 and 100%. Poor response with 0-24% improvement in scars was reported by none of the patients. Improvement in scars was first noted in majority of the patients after completing two sitting of dermaroller and peel. At the end of 1-year of follow-up, it was observed that all the 49 patients sustained the level of improvement in their grade of scars which was attained at the end of the last procedure [Figure [Figure8a8ac]. Although improvement in the scars as noticed by the patient and the physician continued in the follow up period of 1 year, there was no further shift in the grade of scars.

Table 2
Physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system
Figure 1
(a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment
Figure 2
(a) Grade 4 acne scars; (b): Improvement in acne scars from Grade 4 to Grade 3 after treatment
Figure 3
(a) Grade 3 acne scars; (b) Post-treatment patient had no scars
Figure 4
(a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 1 after treatment
Figure 5
(a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 2 after treatment
Figure 6
(a) Grade 2 acne scars; (b) Post-treatment patient had no scars
Figure 7
(a) Grade 2 acne scars; (b) Post-treatment patient had no scars
Table 3
Patient's assessment of response to treatment
Figure 8
(a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment; (c): Sustenance of improvement in acne scars from Grade 4 to Grade 2 at 1 year of follow-up

There was improvement in rolling, boxcar and linear tunnel type of scars with little or no improvement in ice pick scars. All patients tolerated the procedure well. Side effects were mild and transient. Post-dermaroller transient erythema and oedema lasted for 1-4 days with a mean of 2.4 ± 0.7 days. Post-peel exfoliation of skin was present from 2 to 7 days with a mean of 4.4 ± 1 day. Only three patients (6%) developed post-inflammatory hyper-pigmentation (PIH) which was treated with sunscreen in the morning and triple combination of tretinoin, hydroquinone and mometasone at night time. The PIH subsided after 5 months of topical treatment. One patient (2%) developed mildly tender cervical lymphadenopathy each time after dermaroller which lasted for around 3 weeks and subsided on its own. There was no interference in daily activity with no loss of days at work.

 

DISCUSSION

This study has shown good results in patients with severe Grade 4 and 3 acne scars with 10 (62.5%) patients with Grade 4 scars moving to Grade 2 and 5 (22.7%) patients with Grade 3 scars improving to have no scars at the end of treatment. In Grade 2 scars all the 11 patients (100%) showed improvement by 2 grades and were left with no scars. Hence, all 49 (100%) patients showed improvement in their scars by some grade with no failure rate. The physician's analysis also correlated with the patient's assessment of improvement in scars with 12 (75%) patients with Grade 4 scars reporting improvement as very good, 8 (36.4%) patients with Grade 3 scars as excellent and 11 (100%) patients with Grade 2 scars as excellent with poor response reported by none of the patients. The procedure was well tolerated by all the patients. Post-procedure there was no loss of work days and side effects were mild and transient. In spite of patients being of Type III, IV and V Fitzpatrick skin type, only three patients (6%) developed PIH during the treatment, which subsided within 5 months of topical therapy. It has the advantage of being an office procedure and in being cost-effective. Topical tretinoin 0.05% favours the development of a regenerative lattice-patterned collagen network rather than the parallel deposition of scar collagen found with cicatrisation. Since dermaroller opens pores in the upper layer of epidermis and allows creams to be absorbed more effectively, it is for this reason that topical tretinoin was applied during dermaroller and kept for 30 minutes post-procedure to maximise its absorption in skin. Also the improvement in the grade of scars was sustained in the follow-up period of 1 year.

Although ablative laser resurfacing is generally considered to be the most effective option for scar resurfacing, it is associated with significant damage to the epidermis and basal membrane with associated inflammation which causes erythema, scarring and pigmentation problems.[,,] It also has a long downtime. In comparison, percutaneous collagen induction does not induce post-operative dyspigmentation as the epidermis and basal membrane are left intact.[]

 

CONCLUSIONS

As the demand for less invasive, highly effective cosmetic procedures is growing, this combination of treatment for acne scars has shown good results not only in Grade 2 but also in severe Grade 4 and 3 acne scars. The treatment is well tolerated in Fitzpatrick skin types III, IV and V with no failure rates or loss of days at work. There is a high level of patient satisfaction, minimal downtime and the treatment is cost-effective to the patient. To our knowledge, this is the first study using this combination of therapy in the management of atrophic acne scars and the first in which topical tretinoin cream was applied both during and immediately after doing dermaroller.

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. 2014 Jan-Mar; 5(1): 95–97.
 
PMCID: PMC3937506

Subcision plus 50% trichloroacetic acid chemical reconstruction of skin scars in the management of atrophic acne scars: A cost-effective therapy

 

Treatment of acne scars is a dilemma both for the treating physician and the patient as no oral or topical medicine works and it is associated with emotional and psychological stress. Acne scars are classified into three different types: Atrophic, hypertrophic, or keloidal. Atrophic scars are the most common type of acne scars. They have been further classified into three types as described by Jacob et al.[] into ice-pick scars, rolling scars, and boxcar scars. Most of the patients with atrophic acne scars have more than one type of scars.

Various treatment modalities like punch excision and elevation, subcision, chemical peeling using various strengths of TCA, micro-needling, ablative, non-ablative lasers and fillers either singly or in combinations have been described in literature with varying results. Most of these procedures require costly equipment and materials and not affordable by many people.

Subcision or subcutaneous incision-less surgery is a term coined by Orentreich and Orentreich[] in 1995 as the treatment option for atrophic acne scars. Here hypodermic 18 no. needle is used to break the fibrotic strands that tethered the scars to the underlying tissues leading to uplifting of scars. Combining subcision with other scar revision techniques or repeated subcisions may be beneficial to the patients.[] TCA chemical reconstruction of skin scars (CROSS)[] is another useful method for treatment of atrophic acne scars. It involves focal application of 50-100% of TCA with a wooden applicator on the base of an atrophic scar, which causes precipitation of proteins and coagulative necrosis of cells in the epidermis. There is necrosis of collagen in the papillary and upper reticular dermis. Healing is rapid because of sparing of adjacent normal tissues and adnexal structures. So there is reorganization of dermal structural elements and increase in collagen content that leads to filling of the atrophic scar.

While going through the literature, we found that different studies have used subcision and CROSS TCA alone or in combination with other techniques as well as their comparative studies but we did not find any study combining these two techniques together to the best of our knowledge. Encouraged by that, we combined subcision and TCA cross in all types of scars as subsicion breaks the dermal tethering of the scar tissue and TCA will remodel the collagen underneath the scar which treats the basic pathology of the scar to some extent.

In our study, 10 female patients between the age group of 20-35 years of skin type 4 and 5 with atrophic acne scars on the face were randomly selected. Most of the patients had more than one type of atrophic scars of grade 4 severity as described by Goodman.[] In all the patients, there were no active acne lesions and none of them were on oral isotretinoin 3 months prior to inclusion in our study. Patients with keloidal tendencies, bleeding diathesis, and history of recurrent herpes simplex were excluded. Complete hemogram, random blood sugar levels, and viral markers were done in all the patients. Written consent after explaining the risks and benefits of treatment was taken from all the patients along with pre-/post-procedure photographs. Subcision followed by 50% TCA CROSS was done at 4 weeks interval for three sessions. Patients were followed-up monthly for improvement in scars up to 6 months.

Priming was done 2 weeks prior to the treatment with 2% hydroquinone and tretinoin 0.025% cream at night and sunscreen more than 30 sun protection factor (SPF) was given in the morning. Procedure was carried out after application of topical anesthetic cream for 45 min followed by infiltration of 2% Xylocaine with normal saline under aseptic conditions. A no. 18 hypodermic needle attached to a syringe was introduced horizontally underneath each scar and was moved back and forth till the snapping sound was heard. We used no. 18 hypodermic needle because it is cheap and easily available. Homeostasis was maintained by pressure. We cleaned the entire area with normal saline which was followed immediately by 50% TCA with the tip of a toothpick by pressing hard on the entire area of depressed atrophic acne scars irrespective of the type of scar and frosting was taken as the end point, antibiotic cream was applied, and patient was sent home. Patient was advised to apply antibiotic cream twice daily followed by sunscreen in the morning. Erythema, edema, and crusting lasted for 7-10 days in all the patients to varying severity. After 10 days, the patient was advised to apply azelaic acid 20% cream at night.

Results were evaluated on the basis of global scar grading system, visual improvement by photographs and patient satisfaction. The global acne scarring classification is a four-category qualitative system by Goodman[] based on scar morphology and ease of masking by makeup or normal hair patterns. Grade 1 means macular scarring only, Grade 2 is mild atrophy, which is not visible beyond 50 cm and can be easily masked by makeup, Grade 3 is moderate atrophy obvious at social distance not easily masked by makeup while Grade 4 is severe atrophy.

Percentages in improvement were calculated as a combination of the three parameters, i.e. global scar grading system by Goodman, visual improvement by photographs showing the change in the grade and patient satisfaction, which was assessed by giving a questionnaire to the patient where they had to rate their improvement on 0-10 point scale.

Excellent >70%

Good 50-70%

Fair 30-50%

Poor <30%

 

  • We labeled results as excellent when there was a two-grade change in the scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as more than 7 [Figures [Figures11 and and33].
    Figure 1
    Sites involved right cheek. (a) Post-acne scars mostly ice pick, boxcars and few roller scars. (b) Decrease in number and depth of scars
    Figure 3
    Site involved is left cheek and left temple. (a) Many ice pick scars and a few boxcars and very few rolling scars. (b) Decrease in depth and size of scars
  • Results were taken as good when there was one-grade improvement in acne scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as 5, 6, or 7 [Figure 2].
    Figure 2
    Sited involved right cheek. (a) Multiple post-acne ice pick and roller scars. (b) Decrease in size and depth of all the scars
  • Results were taken as fair when there was improvement in acne scars observed by the dermatologist by photographs only and patient rated his improvement as 3, 4, or 5.
  • Results were taken as poor when there was no improvement in acne scars observed by the dermatologist either by photographs or by grading system but it was only subjective improvement as told by the patient when they rated it between 1 and 3.

 

In all the patients, scar grading improved from grade 4 to grade 2 and results were graded excellent, good, and fair in 6, 3, and 1 patients respectively [Table 1]. Although in various studies best results with CROSS TCA are seen in ice-pick scars but since in our study we combined it with subcision, results were equally good even in rolling scars and boxcars scars. Post-inflammatory hyperpigmentation was transient in three patients, which persisted for 15-20 days post-procedure, which further decreased over the time period with 20% azelaic acid and in one case, the mild hyperpigmentation persisted even at the end of 6 months in spite of the best efforts for reasons not known. The patients were also happy with the results except for the one where hyperpigmentation persisted. Although the procedure has a downtime in the form of erythema, edema, and crusting, it is comparable to all other resurfacing procedures and the problem of post-inflammatory hyperpigmentation can be judiciously tackled with the proper and repeated use of sunscreens and lightening agents. Each procedure when done individually has downtime of few days. So, we tried to reduce it by combining the two procedures. Hence, it can be concluded that subcision combined with TCA CROSS is a simple, safe, and cost-effective procedure, which does not require any specialized or costly equipments or materials or any special training and can be performed as an out-patient-department procedure by any budding dermatologist.

 

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  1. Totally agree with the results, firmly believe that manual scar revision yields better overall targeted improvements in the majority of scars. Subcision is especially useful in most cases. Just reviewing the articles, in some cases grade 4 scars still remain as grade 4 by Greg's definition (Goodman Baron Scale). Goodman did his initial work on grading scars over a decade ago, it still remains as one of the most accurate methods to scientifically measure scar improvements- however by his definition grade 4 scars can be markedly reduced, (say by 80% reduction of overall scar count) but still remain as grade 4 as remaining scars can be seen and non-distensible. Example is the first picture. Marked improvement, but still non-distensible.  
  2. Good papers by Italians 3 years ago showing longevity of HA fillers extending past 3 years. Confirms the theory of the manual action of subcsion and filling stimulates collagen in many cases. 
  3. New papers showing normal saline injections with subcision can improve tethered, anchored scars by 30% - read that abstract a few months ago will dig the papers up.  Thanks for sharing the papers with everyone. Most scar specialist perform this method for years. Namely subcise the tethered scars, TCA CROSS the ice pick scars, saline fill as well, then use fractional lasers or microneedling RF - PRP all in the same session. In this context where clinical outcomes are measured, its hard to have a control. Reason is that in real life patients present with a variety of scar types in all ethnicities. The scientific way is to have a control, but other outcomes such as scar count, patient satisfaction rates and modified psychological Derriford scar questionnaires can be used as demonstrated in these papers. Also some good papers from the middle east with 3 point Nokor subcision techniques (think published last 2 years). Third World countries lack the resources of say pico lasers, or even high powered lasers such as Lumenis Ultrapulse (having these two devices will cost half a million dollars to their departments budget). These studies are excellent as they highlight that with limited resources,  manual low cost methods, rather than high cost lasers can yield excellent outcomes-often surpassing high tech lasers. Once again reinforcing that treating the scar type with the best method is the way to go!
https://www.realself.com/review/brisbane-au-acne-scars-treatment-acne-scar-treatment-black-skin#

This is what I am referring to as uncontrolled real world acne scar revision when someone has to use 9 different methods to treat scars within 2 weeks. Not ideal but if someone has limited time, Specialist have to improvise on the run. Especially difficult given the ethnic skin type of the patient, the scar types, and time constraints. 

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Will do, I tend to just read the papers ie. Print out the pdf, read it once then forget. I am guilty of a poor filing system electronically, as I still like paper reading. Will do my best to categorise and comment on them. Paper confirm what clinicians know for years, of which I am not. Just a geek for science and like BA quest to learn. 

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.
Patients' self-esteem before and after chemical peeling procedure.
Anargyros K1, Eftychia P1, Christos C2, Vasiliki E2, Vasiliki M1, Kaliopi A1, Irene P1, Dimitrios R1, George K1.

 

 
 

Abstract

INTRODUCTION:

Chemical peeling is a safe method, widely used to treat a variety of skin conditions and reduce the aging effects. This study aims to evaluate self-esteem among adolescents who undergo chemical peelings.

MATERIAL AND METHODS:

One hundred and twenty six patients constituted the study group. Sixty seven individuals had undergone chemical peeling for therapeutic reasons and 59 individuals for cosmetic reasons. To assess patients' self-esteem, the Rosenberg's Self-esteem Scale (RSES) was used before and after treatment. The control group included 71 healthy, age- and sex-matched volunteers from the general population. They were also asked to complete the RSES, after the same time interval as the patients.

RESULTS:

The healthy controls (23.01 ± 3.12) presented statistically significantly higher self-esteem than both the groups of individuals who would be submitted to chemical peeling. Furthermore, patients who would undergo peeling for therapeutic reasons (21.58 ± 3.20) had statistically significantly higher self-esteem than those who would undergo the procedure for cosmetic reasons (18.97 ± 3.36). After the chemical peeling sessions, the self-esteem of patients treated for therapeutic reasons (23.48 ± 2.43) and of patients treated for cosmetic reasons (22.83 ± 3.34) improved statistically significantly, while the self-esteem of the healthy controls remained stable, as expected.

CONCLUSION:

Patients who undergo chemical peelings tend to have low levels of self-esteem. Although facial lesions in skin diseases such as acne, acne scars, rosacea, and melasma seem to have negative effect on individuals' self-consciousness, patients who would be submitted to chemical peeling in order to treat wrinkles, loss of radiance, and skin tone clarity have even lower self-esteem. Chemical peelings were shown to favorably affect patient's self-esteem since all patients showed an increase in self-esteem after treatment, while the control group experienced no change.

KEYWORDS:

Self-esteem; chemical peel; cosmetic; therapeutic

 

 2017 Mar-Apr;92(2):212-216. doi: 10.1590/abd1806-4841.20175273.

Efficacy and safety of superficial chemical peeling in treatment of active acne vulgaris.

Abstract

Acne vulgaris is an extremely common condition affecting the pilosebaceous unit of the skin and characterized by presence of comedones, papules, pustules, nodules, cysts, which might result in permanent scars. Acne vulgaris commonly involve adolescents and young age groups. Active acne vulgaris is usually associated with several complications like hyper or hypopigmentation, scar formation and skin disfigurement. Previous studies have targeted the efficiency and safety of local and systemic agents in the treatment of active acne vulgaris. Superficial chemical peeling is a skin-wounding procedure which might cause some potentially undesirable adverse events. This study was conducted to review the efficacy and safety of superficial chemical peeling in the treatment of active acne vulgaris. It is a structured review of an earlier seven articles meeting the inclusion and exclusion criteria. The clinical assessments were based on pretreatment and post-treatment comparisons and the role of superficial chemical peeling in reduction of papules, pustules and comedones in active acne vulgaris. This study showed that almost all patients tolerated well the chemical peeling procedures despite a mild discomfort, burning, irritation and erythema have been reported; also the incidence of major adverse events was very low and easily manageable. In conclusion, chemical peeling with glycolic acid is a well-tolerated and safe treatment modality in active acne vulgaris while salicylic acid peels is a more convenient for treatment of darker skin patients and it showed significant and earlier improvement than glycolic acid.

 

 2017 Dec;16(4):454-459. doi: 10.1111/jocd.12377. Epub 2017 Oct 26.

Efficacy of microneedling with 70% glycolic acid peel vs microneedling alone in treatment of atrophic acne scars-A randomized controlled trial.

Abstract

BACKGROUND:

Microneedling with dermaroller and glycolic acid peels is commonly used for treatment of acne scars.

OBJECTIVE:

To compare efficacy of microneedling alone versus combination of microneedling with serial 70% glycolic acid peel in management of atrophic acne scars.

METHODS & MATERIALS:

Sixty patients with atrophic acne scars were randomized into group 1 receiving microneedling at 0, 6, and 12 weeks and group 2 receiving microneedling at 0, 6, and 12 weeks along with 70% glycolic acid peel at 3, 9, and 15 weeks. Acne scar scoring was performed by a blinded observer using ECCA (Echelle d'evaluation clinique des cicatrices d'acne) scoring at baseline and after 22 weeks. Additionally, patients were asked to grade the improvement in acne scars and skin texture on visual analogue scale (VAS).

RESULTS:

Of 60 patients, 52 completed the 22-week study period. The decrement from baseline in mean ECCA score was more in group 2 as compared to group 1 (39.65±2.50 vs 29.58±0.18; P<.001). Group 2 also showed more improvement in skin texture as compared to group 1 on VAS.

CONCLUSION:

Addition of sequential 70% glycolic acid peel to microneedling gives better scar improvement as compared to microneedling alone. In addition to this, it also improves skin texture.


 

 2017 Nov;43 Suppl 2:S163-S173. doi: 10.1097/DSS.0000000000001281.

Chemical Peels: Indications and Special Considerations for the Male Patient.

Abstract

BACKGROUND:

Chemical peels are a mainstay of aesthetic medicine and an increasingly popular cosmetic procedure performed in men.

OBJECTIVE:

To review the indications for chemical peels with an emphasis on performing this procedure in male patients.

MATERIALS AND METHODS:

Review of the English PubMed/MEDLINE literature and specialty texts in cosmetic dermatology, oculoplastic, and facial aesthetic surgery regarding sex-specific use of chemical peels in men.

RESULTS:

Conditions treated successfully with chemical peels in men include acne vulgaris, acne scarring, rosacea, keratosis pilaris, melasma, actinic keratosis, photodamage, resurfacing of surgical reconstruction scars, and periorbital rejuvenation. Chemical peels are commonly combined with other nonsurgical cosmetic procedures to optimize results. Male patients may require a greater number of treatments or higher concentration of peeling agent due to increased sebaceous quality of skin and hair follicle density.

CONCLUSION:

Chemical peels are a cost-effective and reliable treatment for a variety of aesthetic and medical skin conditions. Given the increasing demand for noninvasive cosmetic procedures among men, dermatologists should have an understanding of chemical peel applications and techniques to address the concerns of male patients.


J Drugs Dermatol. 2016 Nov 1;15(11):1413-1419.
Combination Therapy for Acne Scarring: Personal Experience and Clinical Suggestions.
Kroepfl L, Emer JJ.

Acne is one of the most prevalent skin conditions seen by dermatologists. The cosmetic sequelae of severe acne, including scarring and pigmentation, have a profound psychological impact on those inflicted. Topical (eg, retinoids, antibiotics, dapsone, hydroxyacids) and oral treatments (eg, antibiotics and/or spironolactone) are often beneficial to control acne or in the instance of oral isotretinoin use, rid the acne permanently; however, these treatments have very little affect on the ultimate cosmetic outcome of the acne scarring and skin texture that results. Given the variety of scar types that can form and the variability of responses seen in various skin types and textures, treatment options are vast without appropriate guidelines for pathways that dictate best timing, combinations, and options in given clinical scenarios. Current treatment options include solo or combinations of energy-based (eg, laser, radiofrequency), chemical-based (eg, peels, TCA cross), surgical-based options (eg, subcision, punch excision), microneedling, and **fillers and/or fat injections. Most recently, fractional radiofrequency-based treatments have been used to improve acne scarring with less reported downtime as compared to lasers or chemical peels and the ability to treat darker or sensitive skin types with less risk of scarring or hyperpigmentation. In severe cystic ares, scarring treatments are often postposed till the acne is under control and in many instances this can limit the dermatologists ability to affect future cosmetic treatments. Based on personal experience of various clinical scenarios in a busy laser practice that treats a signicant number of patients with acne scarring, fractional radiofrequency is an excellent choice for treating all forms of acne scars with minimal risk to patients. Additionally, fractional radiofrequency can be used in combination with all other treatment options to speed the time to clinical improvement appreciated by the patient. Here we present personal experiences of combination treatments for acne scarring, pigmentation and textural issues, and suggest that fractional radiofrequency be considered a "gold standard" treatment of acne scarring in those with dark or sensitive skin types or those on concurrent treatments where their epidermis stays protected.

J Cosmet Dermatol. 2017 Jun;16(2):186-192. doi: 10.1111/jocd.12311. Epub 2017 Mar 23.
Use of nanofractional radiofrequency (Infini / Intracel / Secret / Intensif / rf microneedling) for the treatment of acne scars in Indian skin.
Goel A1, Gatne V1.

BACKGROUND:
Pitted acne scars of all types remain notoriously challenging to treat with no satisfactory treatment modality, particularly true for darker Fitzpatrick skin types such as Indian skin.
AIM:
Nanofractional radiofrequency has been shown to be an effective treatment modality for the cosmetic improvement of acne scars.
METHODS:
Twenty healthy male and female Indian patients aged 16-60 years with Fitzpatrick skin types IV-V and moderate-to-severe acne scar lesions received 1-3 treatments with a nanofractional radiofrequency device (Venus Viva) at baseline and at 3- to 6 week intervals and were evaluated with photographs at each treatment visit and up to 6 months after the final treatment session. Patients reported on their satisfaction with the treatment. The safety of treatments was evaluated by the frequency, severity, and type of adverse events.
RESULTS:
The majority of study patients achieved improvement in the appearance of their acne scar lesions. There was less improvement on ice pick scar compared to box and rolling type scars, with less impact on ice pick scar type. Overall patient satisfaction from treatment at the 6-month follow-up visit was very high. Adverse events were mild but transient in nature.
CONCLUSION:
The data and results presented here support the efficacy of nanofractional radiofrequency used for the cosmetic improvement of acne scar lesions in facial skin. Moreover, the favorable adverse event profile witnessed in this trial underscores the safety of this technology for cosmetic facial treatments such as facial acne scar lesion therapy in darker Fitzpatrick skin types.

_______________________________________________________
The Limitations of Skin Resurfacing Techniques - Premature Aging of Acne Scar Skin

There are three main facial cosmetic problems for which resurfacing alone is unlikely to provide the complete answer. First there is the dynamism of facial movement. The etching of the lines of recurrent movement in sun-damaged skin will be improved by resurfacing. However resurfacing does not address movement and these lines will be back in time. Lines produced by hyperkinesis such as those of the glabella, forehead, lateral canthus, and nasal areas are best dealt with by paralyzing the lines by botulinum toxin ” or by direct muscle resection.”1' If botulinum toxin is to be used it is probably best to perform this 1-2 weeks before resurfacing. Muscle resection is able to be per¬ formed at the time of the resurfacing. An alternative option is by using filling agents to put a barrier in the way of movement. This may be performed at any time. 

The second factor limiting the efficacy of resurfacing techniques is skin redundancy. Redundant skin occurs as the facial skeleton and the deeper soft tissues, especially the subcutis, diminish with age. It is true that resurfacing will cause some tissue shrinkage but some degree of tailoring of the skin and underlying musculature will be required in some patients. The patients, for whom resurfacing is insufficient therapy for their skin redundancy, should be advised of this before operation and other options explored.” The third limiting factor for resurfacing is the presence of a substantial volume deficit. Disease-inducing deep dermal and subcutaneous atrophy may occur as a result of various disease states or as part of the aging process. Discoid lupus erythematosus, scleroderma, past radiotherapy, and Romberg's facial hemiatrophy may induce facial disfigurement requiring soft tissue augmentation where resurfacing procedure may not be necessary, possible, or desirable. However, scarring from surgery and acne is a major indication for combining resurfacing and soft tissue augmentation. Aging seems to unfairly treat the acne-scarred patient with the tendency to prematurely age the areas most affected by the scarring process. Complex cicatricial patterns may involve epidermis, dermis, and subcutis with both bound-down scars and loss of structure necessitating a combination of several techniques. 

Aging changes add another group of patients that require composite correction of deep and superficial disease. Thinning lips, deepening mesolabial and marionette lines, together with the diminished subcutaneous tissue of aging requires just as much attention as the surface texture changes. The superficial rhytides and sun damage is certainly well managed with resurfacing but the deeper changes are not. Patients will often deliberately increase their body weight as they age to offset this loss of facial fullness. As thin people age they will often look gaunt and tired due to this resorption. These changes often require soft tissue augmentation such as dermal and fat augmentation as well as what¬ ever resurfacing procedure is employed.


http://journals.lww.com/dermatologicsurgery/Citation/1998/06000/The_Limitations_of_Skin_Resurfacing_Techniques_.15.aspx

______________________________________________________________________________________

** Please Do See our Chemical Peel Guide For All things peels (pinned to the top of the scar treatments main sub; learn how to do them)

Chemical peels effective for mild to moderate

acne & scarring

    chemical peel procedure

    Superficial and medium depth peels could be an effective treatment option for patients with mild to moderate acne, says a recent review. (koldunova - stock.adobe.com)

    February 4, 2019
     

    Over the last 30 years, the science of chemical peeling has evolved dramatically, improving our understanding of the role of peeling ingredients and their potential to treat acne and acne scarring.

    Superficial peels which produce injury limited to the epidermis are effective for mild to moderate acne, says a review of the use of peels by the International Peeling Society (IPS) in the Journal of the American Academy of Dermatology.1 In darker skin types, superficial peels are safe and effective in reducing papule, pustule, and comedone count.

    Medium depth peels which produce injury into or through the papillary dermis can be used to treat acne scarring. “Careful patient and peel selection will ensure procedural success with excellent results,” says Kachiu Lee, a dermatologist in Providence, RI and one of the authors of the review.

    Novice peelers should start with superficial peels on Fitzpatrick Skin types I and II so that they can get used to the acids, applicator types and techniques with minimal risk of adverse side effects, she advised. “The difference between satisfactory versus excellent results depends on the selection of the proper peeling agents and the understanding of gentle versus aggressive application technique during their use.”

    Superficial peels

    Common superficial peels include glycolic acid, salicylic acid, Jessner’s solution, retinoic acid, lactic acid, mandelic acid, pyruvic acid and trichloroacetic acid (TCA) 10-35%. Of these, only glycolic and pyruvic acid peels require neutralization, either by sodium bicarbonate or by removal with water. Superficial peels may be grouped into alpha and beta-hydroxy acids. Alpha-hydroxy acids, such as glycolic acid, are water soluble. Beta-hydroxy acids, such as salicylic acid, are lipid soluble.

    Salicylic acid (SA) is a beta-hydroxy acid and a phenolic compound with anti-inflammatory, antimicrobial, and depigmenting properties, and is safe in all Fitzpatrick phototypes. It is particularly effective for comedonal acne because of its lipophilic and comedolytic effect.2

    When SA 20%-30% is in an ethanol (hydroalcoholic vehicle [HA]) some patients develop SA-HA ‘hot spots,’ or areas of over-penetration, that may result in post-inflammatory hyperpigmentation (PIH), so a polyethylene glycol (PEG) vehicle was developed that slows delivery, while simultaneously increasing follicular penetration. A split-face study found that 30% SA-PEG was superior to 30% SA-HA,3 which yields mild desquamation after two days.

    Glycolic acid (GA) is a water-soluble, alpha-hydroxy acid, and pyruvic acid (PA) is an alpha-keto acid. To avoid over penetration, GA and PA must be neutralized as soon as the clinical endpoint of erythema is reached, or after 5 minutes if no erythema is present. Sometimes erythema quickly progresses to frosting and this rapid transition is associated with scar or PIH, and, consequently, there has been a shift towards safer alternatives, such as SA, MJS, or low-strength GA.

    A split-face randomized control trial found SA 30% and GA 30% were similarly effective in treating acne,4 and another study found that SA or salicylic-mandelic acid peels were better than GA peels.5

    Trichloroacetic acid (TCA) is highly water soluble, with no crystallization in up to 90% TCA solution. Depth of penetration correlates directly to concentration and TCA over 35% is used for focal treatment of individual lesions, since pigmentary complications and scars are common with use over large areas.  TCA >80% is only appropriate for focal use, such as chemical reconstruction of skin scars (CROSS); it increases collagen deposition and decreases scar depth of focal ice pick or boxcar acne scars.

    All-trans retinoic acid or tretinoin peels cause minimal discomfort during application because of their nearly neutral pH and intranuclear action.  “Tretinoin peels at varying concentrations may be used to treat acne, although supportive clinical trial data is sparse,” Lee says.

    Jessner’s solution consists of 14% resorcinol, 14% salicylic acid and 14% lactic acid (LA) in 95% ethanol. Resorcinol may cause contact allergy, and risks inducing cross-sensitivity with hydroquinone, with repeated exposure so modified Jessner’s solution (MJS) was created by increasing the concentration of SA and LA to 17% and replacing resorcinol with 8% citric acid.

    Medium depth peels

    Historically, medium depth peels were performed using TCA 50%, which resulted in uneven penetration and erosions, PIH and scars. Safer medium depth peels have been developed and include 70% glycolic acid+35% TCA (Coleman peel), Jessner’s solution (JS)+35% TCA (Monheit peel), solid C02+35% TCA (Brody peel).

    Medium depth chemical peels using solid C02 slush with focal 50% TCA to efface scar rims6 or JS followed by 35% TCA may improve acne scars in lighter skin types. Focal dermabrasion may follow the peel.7

    Solid C02 slush is created by dipping hand-held blocks of solid C02 (-78.5°C) in a 3:1 acetone to alcohol solution and allowing it to glide smoothly over the skin, which has been degreased with acetone, for 3 to 15 seconds until there is transient white frost with residual erythema. TCA is then applied until even light white or solid white frost is achieved, which corresponds to epidermal and dermal protein denaturation.

    The Monheit peel uses JS instead as a keratolytic agent to further TCA penetration, and is performed by degreasing the face with acetone and then applying JS until a reticulate frost is obtained. MJS can be used in darker skin to treat pigmentation and has less risk of contact sensitivity. 

    With the Coleman peel degreasing with acetone is unnecessary if patients are not wearing make-up or other products. GA 70% is first applied for approximately 2 minutes until erythema develops, then neutralized before TCA 35% is applied.
    Solid C02+ TCA is histologically the deepest medium depth peel and easier for the patient to tolerate than JS or GA followed by TCA. Analgesia is unnecessary for any medium depth peel if the operator is experienced in performing the peel rapidly and smoothly, Lee says.

    Preparation and aftercare

    Medium depth peels are not recommended for phototypes ≥IV due to the risk of post-inflammatory hyperpigmentation, but this risk may be reduced by pre-peel preparation with hydroquinone for 1 month and peeling during the winter season.

    For superficial and medium peels, pre-treatment with topical tretinoin for 2-4 weeks enables a more uniform frosting and improves healing time. It is recommended that tretinoin is stopped one week prior to the peel in skin types IV-VI to prevent overpenetration and PIH. Pretreatment for 2 weeks with hydroquinone 2% is associated with less PIH.

    Post-peel management focuses on expediting healing and preventing infection. Icepacks can be used for edema and mild discomfort, and gently soaking and cleansing the skin and applying white petrolatum promotes re-epithelialization. Patients with a history of herpes simplex virus should receive medical prophylaxis.

    Sun protection is vital before and after the peel. Physical barriers should be used until re-epithelialization, then a physical sunscreen can be applied.

    References:

    1 Lee KC, Wambier CG, Soon SL, Sterling JB, Landau M, Rullan P, Brody HJ, on behalf of the International Peeling Society(IPS), Basic chemical peeling—superficial and medium depth peels, Journal of the American Academy of Dermatology (2019), doi: https://doi.org/10.1016/j.jaad.2018.10.079

    2 Dainichi T, Ueda S, Imayama S, Furue M. Excellent clinical results with a new preparation for chemical peeling in acne: 30% salicylic acid in polyethylene glycol vehicle. Dermatol Surg. 2008;34(7):891-899.

    3 Dainichi T, Ueda S, Imayama S, Furue M. Excellent clinical results with a new preparation for chemical peeling in acne: 30% salicylic acid in polyethylene glycol vehicle. Dermatologic Surg. 2008;34(7):891-899.

    4 Kessler E, Flanagan K, Chia C, Rogers C, Glaser DA. Comparison of alpha- and beta555 hydroxy acid chemical peels in the treatment of mild to moderately severe facial acne vulgaris. Dermatol Surg. 2008;34(1):45-50.

    5 Garg VK, Sinha S, Sarkar R. Glycolic acid peels versus salicylic-mandelic acid peels in active acne vulgaris and post-acne scarring and hyperpigmentation: a comparative study. Dermatol Surg. 2009;35(1):59-65.

    6 Brody HJ, Hailey CW. Medium-depth chemical peeling of the skin: a variation of superficial chemosurgery. J Dermatol Surg Oncol. 1986;12(12):1268-1275.

    7 Al-Waiz MM, Al-Sharqi AI. Medium-depth chemical peels in the treatment of acne scars in dark-skinned individuals. Dermatol Surg. 2002;28(5):383-387.

     

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    Quite interested in those TCA peel entries. I've tried looking for medical literature on TCA peels for acne scars and found scant few.

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    This is why I believe fillers are absolute game-changers.  You will not get those kind of results from lasers - EVER.  I can't wait for the time when we have reversible hyaluronic acid fillers that last 5 years or more.  

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    On 1/16/2018 at 6:19 PM, dazzed said:

    This is why I believe fillers are absolute game-changers.  You will not get those kind of results from lasers - EVER.  I can't wait for the time when we have reversible hyaluronic acid fillers that last 5 years or more.  

    It's because they are quicker fixes. But they still require upkeep though.

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    14 hours ago, Runawayspaceship said:
    On 1/16/2018 at 6:19 PM, dazzed said:

    This is why I believe fillers are absolute game-changers.  You will not get those kind of results from lasers - EVER.  I can't wait for the time when we have reversible hyaluronic acid fillers that last 5 years or more.  

    It's because they are quicker fixes. But they still require upkeep though.
     That's all I've been saying. New to the forum? Edited by dazzed

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    Efficacy of a combination of diluted calcium hydroxylapatite‐based filler and an energy‐based device for the treatment of facial atrophic acne scars

    Quote

    Note by BA: Hence Over Dilute Sculptra (Widespread Scar; Fat Deficiency) and Radiesse (Individual Pits) can be used as a foundation with Acne Scarring with energy devices for rejuvenation and collagen formation, HA can be used with scubcision to act as a spacer and prevent re-ethering, cause collagen formation...

    First published: 21 February 2019
     

     

    Summary

    Background

    Treatment options for atrophic acne scars include the use of various energy‐based devices (EBDs) and dermal fillers.

    Aim

    To evaluate the level of improvement and safety of four treatments for atrophic acne scars used in our centre.

    Methods

    We reviewed the medical records of all patients with acne scars treated between 2013 and 2016 with one of four treatments: ablative fractional CO2 laser (FACL), a radiofrequency (RF) bipolar device, a 1540 nm nonablative fractional laser (NAFL) and injection of diluted calcium hydroxylapatite (CaHA). The EBDs were used either as monotherapy or in combination with diluted CaHA. The aesthetic improvement achieved following the various treatments was evaluated by the patients and by two independent dermatologists who were not involved in the treatments. The patients also rated their satisfaction with the treatment, recorded the number of days of downtime (including time to full recovery and time for resolution of redness) and reported any adverse effects (AEs).

    Results

    In total, 352 patients (mean ± SD age 28.7 ± 8.7 years; 65.6% women, 34.4% men) were treated for acne scars. The integrated mean Global Assessment Scale by both dermatologists and patients were highest for the combined CaHA–FACL treatment at separate sessions (injection in one session; laser treatment in another) (P < 0.001). However, patients treated with FACL reported more AEs and longer downtime and duration of erythema.

    Conclusion

    The combination of a diluted CaHA‐based filler injection followed by FACL in separate treatment sessions yielded better aesthetic improvement compared with the other tested treatments.

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    9 hours ago, beautifulambition said:

    “We demonstrated that the inflammatory response is still present in 21-days lesions in acne patients prone to scarring compared to those who do not develop scars, suggesting a difference in the acne lesion life-cycle between the two populations,” Dr Johannes Josef Voegel said.

    “Inflammatory lesions persist after three weeks only in patient with scars, with an exacerbation of number and modulation of genes involved in the immune response. This was in line with higher influx of T cells and macrophages observed by immunohistochemistry.”


    I'm not at all surprised by this finding. Inflammation is part of our immune response and any prolonged inflammation is a good indication of poor immunity, namely your health is really messed up. As such, I'm a big proponent of balanced gut health. A healthy gut equals healthy body and mind.

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    What I got from this is that genetics plays a huge role in how you heal. If one has a family history of severe acne, this shows that it is imperative that you hit the acne hard and early.   Cases like these do not "clear up on their own."    For me, the worst triggers were stress and lack of sleep.   For people with a family history, we have to adhere strictly to a regimen to prevent it from getting out of control.  

    If you are starting to get cysts, and if they begin to scar, you need to get on Accutane immediately.   Prevention is the only way to not deal with severe scars.  

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    Frequency of Acne Scar Treatment & Filler Longevity:

    We are often asked "why can't I treat every 2 weeks, 4 weeks, 1 month." Collagen is notoriously slow to build and can take up to a year in "some" people. Over treatment can lead to damaging the process of collagen formation or as a side effect of energy devices damage the collagen. This leads to a constant state of swelling where these side effects are hidden and constant treatments are done at the Drs over recommendation.This is why we recommend treatment at least every 3 months for energy devices. You can see what works and what doesn't. How your body heals and what it responds to favorably. Providers will push multi-treatments, sometimes 5 or more things at once as close together as possible. They strike while the fire is hot... $$$$.Otherwise you may think about your treatment or observe it. Some providers do have the best intentions with multi-treatments, ... say your flying from out of town / the country or you say you have no time for any down time. In these cases it's understandable to do multiple things at once for higher risk of side effects.This is why one cannot also treat just once with 5 treatments (at once) and be done with their scars, ... it's just not how the body heals. Think of your scabs or bruises the last time you had some. It took a long time to heal right. Your acne scars have been with you for many years, the body must cooperate in healing to treat. Over treatment can be un-beneficial for the patient and their fiances. Who needs filler 5x a year unless your a body builder with heavy movement or your have a high movement area of the face (botox).

    ** Note "at home" microneedling, microdermabrasion, and lighter peels are not considered 3- month treatments, .. monthly treatments are fine.

    It might be best to learn to say to the Dr, "I will call you back to schedule or cancel and reschedule if you get the hard sale / push." 
     

    Energy Devices in General like (Fractional - Lasers), Rf Microneedling, and Deeper Acid Peels, provides increased improvement six months after the last treatment

     

    "When any wound is created, whether traumatically, or surgically, there is a wound healing cascade that is initiated. Multiple things occur underneath the skin that are not visible to the naked eye.  An infantile form of collagen is first formed and then as the wound matures, the body dissolves that collagen and lays down a mature form of collagen. Then this collagen over many months integrates in a stronger formation, similar to pick up sticks falling on the ground and then someone laying them neatly together in parallel groupings.  Inflammatory cells are also recruited into the area to keep it clean and new blood vessels form, microscopically, to bring in more oxygen that is needed for the new collagen to form.Typically there are biochemical and clinical changes in healing scars that are seen even up to 18 months after surgery, but this is why with Fraxel, that there is continual improvement in collagen build-up and even tightening possibly, for six months."

    ____________________________________________________________________________

    Prolonged Clinical and Histologic Effects from CO2 Laser Resurfacing of Atrophic Acne Scars
    Sunila Walia MD  Tina S. Alster MD
    Objective. The aim of this study was to determine the immediate and long‐term (12–18 months) histologic and clinical effects of atrophic acne scars after CO2 laser resurfacing in order to provide physician guidelines for postoperative clinical assessment for retreatment.

    Methods. Sixty patients (50 women, 10 men, mean age 38 years, skin types I–V) with moderate to severe atrophic facial scars were evaluated. Nineteen patients received regional cheek treatment and 41 patients received full‐face resurfacing with a high‐energy pulsed CO2 laser. Independent clinical assessments of treated scars were performed at 1, 6, 12, and 18 months and blinded histologic analyses were made of skin biopsies immediately prior to and after laser resurfacing, and at 1, 6, 12, and 18 months postoperatively in six patients.

    Results. Significant immediate and prolonged clinical improvement in skin tone, texture, and appearance of CO2 laser‐irradiated scars was seen in all patients. Average clinical improvement scores were 2.22 (69%) at 1 month, 2.1 (67%) at 6 months, 2.37 (73%) at 12 months, and 2.5 (75%) at 18 months. Continued collagenesis and subsequent dermal remodeling were observed on histologic examination of biopsied tissue up to 18 months after surgery.

    Conclusion. Continued clinical improvement was observed as long as 18 months after CO2 laser resurfacing of atrophic scars, with an 11% increase in improvement observed between 6 and 18 months postoperatively. We propose that a longer postoperative interval (12–18 months) prior to assessment for re‐treatment be advocated in order to permit optimal tissue recovery and an opportunity for collagen remodeling.

    ____________________________________________________________________________

    Healing from Treatment of Scars is sloooooooooow:

    Current Concepts in Pediatric Burn Care: The Biology of Cultured Epithelial Autographs: An Eight-Year Study in Pediatric Burn Patients *
    Carolyn C. Compton -Departments of Pathology, Shriners Burns Institute and Massachusetts General Hospital, Boston, MA, USA

    Abstract

    22-year history of histopathological skin regeneration and wound healing in 22 pediatric patients treated with cultured epithelial autografts (CEA) excised to full-thickness burn wounds. Biopsies of CEA have been analyzed by light microscopic, immunohistochemical, morphometric, electron microscopic and ultrastructural immunolabelling techniques and compared to controls of meshed split-thickness autograft (MSTA). At transplantation, CEA are undifferentiated and varicose both granular and cornified cell layers. Postgrafting, CEA differentiate all normal epidermal strata but lacquer rete ridges. De novo formation of a confluent basal lamina and mature hemidesmosomes is complete by several weeks. Anchoring fibrils appear sparse and immature (as in MSTA controls) compared to normal skin for about 6-12 months. CEA develop rete ridges and a neodermis with normal stromal and vascular organization at about 6-12 months, MSTA interstice controls do not.  At 4-5 years, elastin expression is thus observed in the CEA neodermis, completing the dermal regeneration process.  Normal epidermal differentiation is maintained long-term.  These long-term results indicate that CEA regenerate a stable normal epidermis and are capable of inducing dermal regeneration from wound bed connective tissue.  elastin expression is thus observed in the CEA neodermis, completing the dermal regeneration process.  Normal epidermal differentiation is maintained long-term.  These long-term results indicate that CEA regenerate a stable normal epidermis and are capable of inducing dermal regeneration from wound bed connective tissue.  elastin expression is thus observed in the CEA neodermis, completing the dermal regeneration process.  Normal epidermal differentiation is maintained long-term.  These long-term results indicate that CEA regenerate a stable normal epidermis and are capable of inducing dermal regeneration from wound bed connective tissue.

    Summary

    This long-term control study reports on the histopathological 8-year results in 22 severely burned children in whom third-degree burn wounds after excision, except for the muscle fascia, were covered with keratinocyte cultures.  The biopsies were examined by light microscopy, immunohistochemistry, morphometry, electron microscopy and by means of ultrastructural immune markers and compared with biopsies obtained from conventional split skin grafts, which had been transplanted in an analogous manner and at a similar time.  These biopsies come from the epithelialized spaces of the mesh grafts.  At the time of transplantation, the keratinocyte cultures are undifferentiated and show neither a stratum granulosum nor a stratum corneum.  Six days after transplantation, all normal layers of the epidermis are detectable, but the rete strips are missing.   Immature anchor fibrils are sparse within the first 6-12 months after transplantation (similar to the biopsy after split-thickness coverage) compared to normal skin.

    Within the first 6-12 months after surgery, the keratinocyte cultures develop rete ridges, forming a neodermis with normal stromal architecture and vascular supply.  The control biopsies, however, do not show these findings.  4-5 years after transplantation, formation of elastin is observed in the keratinocyte neodermis, suggesting the maturation of the dermal regeneration process.  The normal structuring of the epidermis is preserved for years.

    These long-term results show that the keratinocyte cultures are able to regenerate both a normally structured epidermis and are also capable of inducing a normal structured neodermis regeneration from the connective tissue of the wound bed.

    ____________________________________________________________________________

    In Vivo Histological Evaluation of a Novel Ablative Fractional Resurfacing Device : Lasers in Surgery and Medicine


    Basil M. Hantash, MD, PhD, Vikramaditya P. Bedi, MS, Bhumika Kapadia, BS, Zakia Rahman, MD, Kerrie Jiang, NP, Heather Tanner, MS, Kin Foong Chan, PhD, Christopher B. Zachary, MBBS

     "...Immunohistochemical studies of heat shock proteins revealed a persistent collagen remodeling response lasting at least 3 months.""

    "...Zweig et al. [6] speculated that the delayed healing was secondary to the large thermal damage zone induced by the ablative treatment, rendering the coagulated collagen ‘‘mummified’’ in the dermis for several months."

    "...Remarkably, hsp47 expression has increased and become more diffuse at 3 months consistent with continued collagen synthesis and remodeling (Fig. 4F)."

    "...In particular, expression of hsp47 became diffuse in the dermis at 3 months post-treatment, indicating that activation of fibroblasts was occurring in both treated and untreated tissue"

    "... Diffuse upregulation of hsp47 expression provided conclusive evidence that neocollagenesis was persistent for a minimum of 3 months post-treatment, ensuring long-term generalized dermal remodeling that may rival conventional CO2 and Er:YAG laser resurfacing"

     

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    A cross-sectional study of clinical factors associated with acne facial scarring in patients with active acne - 2018 

    Clio Dessinioti, MD1 , Chrisa Zisimou, MD1 , Effie Platsidaki, MD1 , Andreas Katsambas, MD2 , Christina Antoniou, MD1

    Scarring may occur in 45% to 55% of acne patients, it may produce significant psychopathology, and it is challenging to treat.1,2,3 Identifying factors associated with acne scars may assist in their prevention strategy. We conducted a cross-sectional study to investigate clinical factors associated with acne facial scarring at first visit, including age, sex, smoking, family history of acne, and the history of previous acne treatments. Active acne on the face was graded by the Global Evaluation of Acne (GEA) scale (0-5), as previously described.4 The presence of acne scars (atrophic or hypertrophic) on the face, or macular erythema, was recorded. The hospital IRB approved the study. Statistical significance level was set at P < 0.05. In total, 167 acne patients were included (65% women). Acne scars on the face were found in 39% patients.

    Atrophic acne scarring was the most common type (97%). Most patients with facial acne scarring (72%) also had macular erythema present (p<0.001). There was no association of smoking with acne scarring (p:0.916), however most patients (76%) were non-smokers. Acne scarring was associated with gender (p:0.037), and a history of oral acne treatments (p:0.041) (Table 1). In multivariate logistic regression analysis adjusting for gender, duration of acne, and a history of previous oral treatments, acne facial scarring was associated with male gender (OR: 2.76, 95% CI: 1.32-5.75), and the history of oral acne treatments (OR: 2.52, 95% CI: 1.21-5.22), but not with the duration of acne (OR: 1.02, 95% CI: 0.95- 1.10) (Table 2).

    Acne facial scarring was common (39%) in our study, and atrophic scarring was the predominant type (97%).1,2,5 The severity and the duration of acne were not associated with scarring in our study, suggesting that scarring may occur with any type of acne5 , even early after acne development. It may be not the duration of acne per se, but the duration of inflammatory exacerbations of acne that predispose to scarring. The history of oral acne treatments was associated with more than 2-fold increased risk for acne facial scarring in our study.

    Acne necessitating oral treatment may be associated with higher risk of acne scarring, due to higher inflammation. An immunohistochemical case-control study showed that scarring patients had increased specific immune response in resolving lesions, with prolonged inflammation.6 It was suggested that early treatment of inflammatory acne may prevent acne scarring.6 Papules of longer duration were significantly more likely to change into acne scars compared with rapidly resolving lesions.3 Smoking was not associated with acne scarring in our study, similarly with one other report investigating acne scarring and smoking.7 Smoking has been associated with comedonal adult acne with only few inflammatory lesions.8

    Male patients with acne had an almost 3-fold increased risk for acne facial scarring compared to women, in our study, similarly to significantly higher rates of scarring reported in men compared to women (50.7% vs 44.5%).9 This may be attributed to a higher threshold for seeking medical treatment or to lower adherence rates.

    Macular erythema was noted in most of our patients with acne facial scarring. Macular erythema may be a clinical sign of importance related to inflammation and atrophic acne scars. Erythematous macules preceded (11.9%) or appeared after (36.8%) the inflammatory acne lesions in a 12-week study.10 Atrophic acne scars originated by 83% from post-inflammatory lesions including macular erythema, and by only 16% from inflammatory acne lesions.5

    Our study showed that future directions to prevent the risk of facial scarring in acne patients may include the understanding that acne scarring may occur even with milder acne forms, the prompt and early treatment of inflammatory acne lesions and recognizing male patients as a group at increased risk for acne scarring. Whether appropriate treatment of the macular erythema may prevent the formation of acne scarring may be worth investigating.

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    . 2015 Dec; 69(6): 384–386.
    PMCID: PMC4720458
    PMID: 26843730

    Can Subcision with the Cannula be an Acceptable Alternative Method in Treatment of Acne Scars?

    Abstract

    Background and objectives:

    Most people who experience the acne suffer from damage under the surface of their skin which causes saucer-like depressions or pits on their skin. Sometimes the skin loses its underlying support and develops fibrous bands of tissue between the skin and subcutaneous layer, which pull on the epidermis and cause a wavy texture called as rolling scar. Treatment of acne scars is a therapeutic challenge that may require multiple modalities. Subcision is a procedure that has been reported as a beneficial method in the treatment of rolling acne scars. Although Subcision is a valuable method, its efficacy is mild to moderate because of the high recurrence rate and patients dissatisfaction due to some side effects include post procedure inflammation.

    Materials and methods:

    This pilot study is a clinical trial. The 8 patients suffered from mild to severe rolling acne scars on their face with symmetrical distribution of lesions, underwent Subcision with the Cannula and followed-up for 3 months. Outcomes of Subcision procedures were assessed by 3 board certified dermatologists (blind) after 2 session of treatment. The patients’ satisfaction was considered to compare with dermatologist’s opinions. The degree of improvement and satisfaction of the treatment estimated with these points: poor: 0, fine: 1-3, good: 4-6, and very good: 7-9. The data were finally analyzed with SPSS-18 software.

    Results:

    Subcision with the Cannula showed good and very good improvement in about 88% of patient with a satisfaction good and very good improvement in all of patients (100%). Assessment of photographic data showed 100% improvement in scar depth, topography and overall appearance of acne scars. The average numbers of lesions before the treatment were 24.8 ± 12.1 and after treatment it was reduced to 12.8 ± 2.1 (p<0.05).

    Conclusion:

    Subcision with the Cannula appears to be a safe method with high efficacy in the treatment and high satisfaction in patients as we observed an interesting cure rate (more than 50% after 2 sessions). It demonstrates to be a safe procedure because it performed by single perforation in each side instead of multiple perforations that helps to reduce the patients’ pain and risk of scars. In other hand Cannula-based Subcision needs considerable fewer sessions of surgery and also less recovery time.

    Keywords: Acne Scars, Subcision, Cannula, efficacy, Side effects

    1. INTRODUCTION

    Acne is a common dermatological disorder causing a great cosmetic disfigurement (). Because acne scars can have a different appearance and depth, there are various treatments for them based on the type and severity of tissue damage remains after the healing of first lesion (, , ). Subcision is one of the proposed treatments that have been reported to be beneficial approach especially in post acne deep rolling scars. It is a Known therapeutic method in which we can use different tools. Although it seems that, there had not been a huge difference in the result of using various tools, such as the effectiveness, side effects, duration of procedure and so on, but numerous studies have been conducted in this area to find the best method that in addition to better results can provide a patient and physician satisfaction.

    In a study in 1995 as pioneers () it was reported that Subcision with a traditional needle can be a potential procedure in treatment of skin depressions which can cause the deep rolling scars after acne lesions. Also, some other studies demonstrated that Subcision with a wire scalpel can be an excellent candidate to treat depressed scars, wrinkles, and folds which develop as a result of acne (, , ). Although Subcision has very minimal side effects, depression recurrence is very common issue particularly 2 weeks after first treatment. In other hand the procedure can cause bruising and soreness and sometimes it can forms hematoma. Moreover the risk of infection or prolonged pain is considerable as well. As an alternative to the wire scalpel method to assess the efficacy of Subcision with Cannula, we design herein a modified Subcision technique  (Hakko Co., Chikuma, Japan). As we know, this tool is cheaper than other tools used before and its preparation is easier. The main goal of preparation of this pilot study was to evaluate the effectiveness of this method, duration of treatment, side effects, patient satisfaction and physician satisfaction after using this tool as an alternative to needle. We are looking for a tool with high performance, high efficiency, low recurrence rate, and minimal side effects that are cheap and accessible for patients and convenient for doctors.

    2. MATERIALS AND METHODS

    This is a pilot study. We chose 8 patients who suffered from rolling scars caused by acne. As we know patients’ awareness of the treatment process is very effective in their expectation of the outcome of treatment. So all the stages of treatment, treatment methods and tools that we used, the effectiveness of this method according to the history, and the possible complications explained to patients. The mean age of the participants was 31.2 years and all of them were female. The area to be Subcised (about 10 mm wide) was outlined while the patients were sitting in a fixed and comfortable position. All patients were subjected to 1% lidocaine solution as a local anesthetic and an anti-arrhythmic drug containing 1:100,000 epinephrine. The Cannula was used for Subcision of scars. The Cannula was inserted into the superficial dermis and passed through the sub-dermal plane parallel to the skin surface. Rapid repetitive back and forth motion of the needle was performed to scrape the underside of the dermis and disconnect scar sub-surfaces such as the base, walls, borders and shoulders. Then, side-to-side needle motion called as fanning motion was also introduced to completely release fibrous tissues. ** There are other methods of Subcision application using a cannula. 

    After the final step, ice compression was applied to the site of treatment for 20 minutes. Photos of patients were taken using Vision-face before the start of treatment and after the final step of treatment. Outcomes of Subcision procedures were assessed by 3 board certified dermatologists (blind). Patients’ satisfaction was estimated at the end of the treatment process. The degree of the improvement was rated as follow: poor: 0, fine: 1-3, good: 4-6, and very good: 7-9. The data on target were analyzed using the SPSS-18 software.

    3. RESULTS

    Out of total amount in our sample, 8 patients (female) were enrolled in the study and underwent Subcision with the Cannula. After analyzing the findings of evaluation of photos (took before and after the treatment) by specialists, the results showed good and very good improvement in about 88% of patient. The results of patient satisfaction showed good and very good improvement in all of the participations (100%). Photographic data showed a significant improvement in topography, level of scar depth, and overall appearance of the acne scars in all 8 patients (Figure 1, ,2,2, ,3).3). Patients with mild active acne experienced a reduction in formation of scar after active phase of disease during the treatment and follow-up interval. The average numbers of lesions before the treatment were 24.8 ± 12.1 and after treatment it was reduced to 12.8 ± 2.1 (p<0.05). Transient post procedure mild swelling and inflammations were detected among our patients that were cleared completely after 2 weeks of therapy. Sever swelling, bruising and also skin infection weren’t observed in any cases of under examined patients. There was no evidence of hyper pigmentation or hypertrophic scar. The participations were followed up for 3 months and they were not showed any side effect or recurrence during the course of the investigation.

    An external file that holds a picture, illustration, etc. Object name is MA-69-384-g001.jpg

    Case 1 (female, 42 years). A: before the treatment. B: after the treatment.

    An external file that holds a picture, illustration, etc. Object name is MA-69-384-g002.jpg

    Case 2 (female, 36 years). A: before the treatment. B: after the treatment.

    An external file that holds a picture, illustration, etc. Object name is MA-69-384-g003.jpg

    Case 3 (female, 30 years). A: before the treatment. B: after the treatment.

    4. DISCUSSION

    All surgical techniques are developed and modified continuously with the purpose of achieving the best outcomes through easier, comfortable, and practical ways to get the best final results with fast recovery and the least complications. Prominent skin scar depression can be noticeably improved using a wide range of treatment modalities. To obtain optimal results, the treatment design should be planned according to the patient’s situations such as age, aesthetic needs, anticipated downtime, sensitivity, and so on (). Subcision is a valuable surgical technique that can be applied to lessen depressed scars, wrinkles, striae, cellulite, boxcar and serious pitted scars (). This technique applied generally to control depressed scars. As described by S. Orentreich and N. Orentreich in 1995, Subcision aims to sever the fibrous components beneath the scar, at the sub-dermal stage. It helps to lift up the scar and produce the forming of connective tissues through usual physiological healing (). It was done by using a Nokor or hypodermic needle (needle gauge depends on the size of the scar). Over time, many modifications to this surgical technique have been made by various surgeons in order to make it simpler and more effective. In this study, we assessed all aspects of the use of another special device (Cannula) in Subcision of acne-induced scars that appear to be safe and efficient. We focused on the treatment of acne scars by means of Subcision procedure with the Cannula to break up fibrous bands that cause rolling scars. We observed an interesting cure rate data (more than 50% after 2 weeks) relative to other reported ones (around 30-40%). Hypertrophic scar and hyper-pigmentation, Ecchymosis, swelling and redness are common side effects among Subcision with Needle that are reported in 50% of patients (even increase to 70-80% of patients), but Subcision with the Cannula appears to be a safe method with high efficacy in treatment and high satisfaction in patients (-11). Another superiority of our new designed method is that Subcision with Cannula have been performed by single perforation in each side instead of multiple perforations that helps to reduce the patients’ pain and risk of scars during and after the procedure. Furthermore, Cannula-based Subcision relative to needle-based Subcision needs considerable fewer sessions of surgery and also it requires less recovery time. In general all these advantageous points come to enhancement of patient satisfaction. However, further controlled trials should be conducted to assess the efficacy and side effects of Cannula in comparison with needle and other techniques.

    5. CONCLUSION

    Subcision with Cannula can be replaced instead of other tools that are used in the treatment of the scars caused by acne. This treatment method is less invasive, with fewer complications and more satisfaction of patients. In addition therapeutic techniques using these tools are easier for doctors and they are associated with more satisfaction of them and finally the treatment will done in less time.

    _____________________________________________________

     

    Blunt cannula subcision is more effective than Nokor needle subcision for acne scars treatment

    First published: 09 March 2018
     

    Summary

    Background and aim

    A comprehensive study comparing two different modalities, Nokor needle subcision (NNS) and blunt cannula subcision (BCS), for treatment of acne scars, has not been reported previously. The aim was to compare the effectiveness of these two methods based on patient's and doctor's satisfaction measures, in addition to the late complications 3 months postsubcision.

    Method of intervention

    Patients had 18‐65 years old, with acne scars on both malar sides. They were treated at one malar side with NNS and with BCS at another side. They were monitored during the first week, at one and 3 months postintervention. Patient's and two dermatologist's satisfactions were compared during 3 months, for each modality and between modalities.

    Results

    From 34 patients, 29.4%, 55.9%, and 14.7% had mild, moderate, and severe acne scars, respectively. Ecchymosis, nodule formation post‐NNS, and edema after BCS were the complications. Patients were satisfied with BCS during 3‐month monitoring (P = .021), but not with NNS (P = .353). Physician‐1 was satisfied from the outcome of both BCS and NNS procedures (P = .044 and .006, respectively). However, physician‐2 was only satisfied with NNS at the month 3 than the month 1 (P = .002). All patients and physicians were significantly more satisfied with BCS than NNS (P = .000). Anyway, at the month 3, physician‐2 had no significant different points of view about applied methods (P = .25).

    Discussion

    Considering the complications and satisfaction rates, BCS was more efficient than NNS for acne scar treatment. Then, we suggest BCS as a good replacement for NNS.

    _________________________________________________________

     

     2005 Mar;31(3):310-7; discussion 317.

    Subcision for acne scarring: technique and outcomes in 40 patients.

    Abstract

    BACKGROUND:

    Treatment of acne scars is a therapeutic challenge that may require multiple modalities. Subcision is a technique that has been anecdotally reported to be of value in treating so-called "rolling scars."

    OBJECTIVES:

    To assess the efficacy of subcision in the treatment of "rolling" acne scars.

    METHODS:

    A standard technique was developed for subcision. This was then applied to the treatment of rolling scars in patients, 40 of whom completed treatment and the prescribed follow-up. Six-month follow-up data were obtained from both patients and investigators.

    RESULTS:

    Subcision is associated with patient and investigator reports of approximately 50% improvement. Ninety percent of treated patients reported that subcision improved their appearance. The side effects of swelling, bruising, and pain are transient, but patients may have persistent firm bumps at the treatment site.

    CONCLUSIONS:

    Subcision appears to be a safe technique that may provide significant long-term improvement in the "rolling scars" of selected patients. When complete resolution of such scars does not occur, combining subcision with other scar revision procedures or repeat subcision may be beneficial.

     
    ________________________________________________________________________________________________________

    Turns Out You Don't Need Lasers To Get Rid Of Acne Scars
    LISA SINGH
    NOVEMBER 14, 2016, 11:30 AM


    Whenever someone talks about acne-scar solutions — I'm talking real acne scars, not the post-inflammatory marks left behind — the inevitable answer is almost always lasers. Well, here's something I wish I'd known before spending thousands of dollars on lasers, trying to eradicate the biggest of the acne scars that marred my face after getting hit with a pimple firestorm at age 28: No laser was going to erase those ego-deflating craters that followed a round of Accutane, no matter how much grief they caused me.

    In the frustrating, unfair world of acne, some people don't scar — their bodies produce enough collagen to reverse the fat loss and subsequent divots that are caused by a particularly aggressive pimple — while others are left with a cornucopia of scar variations. And — ready for this? — two of the most common acne-scar types won’t see any discernible improvement with lasers.

    “If you have a significant boxcar or rolling scar, you have to fill what’s missing — volume — and there is not a single laser, radio frequency, or ultrasound device that will bring that back,” says Suzan Obagi, MD, medical director of the Pittsburgh-based UPMC Cosmetic Surgery and Skin Health Center, as well as associate professor of dermatology and plastic surgery at the University of Pittsburgh.

    In case you’re wondering what acne-scar type you have, here’s a quick primer: Boxcar scars have a well-defined border and indent that are visible in any light. Rolling scars are not as apparent in dim light, but when you are sitting in any scenario with bright overhead lights or side-lighting (i.e. lights that create defined shadows on your face), they become very apparent.

    I had mostly rolling scars (with a few boxcar scars) on my cheeks, forehead, left temple, and chin. 

    After countless visits to different derms and multiple laser treatments with Fraxel, Yag, and VBeam to no avail, I was getting desperate. And a conventional non-fractional CO2 laser, which has been shown to be one of the better options for scarring, was off-limits due to my olive skin tone — there is a significant risk of hypo- or hyperpigmentation for olive and darker complexions. Which is what led me to a far less gadgety — yet infinitely more effective — option that’s actually been around for decades: acne-scar subcision.

    Here’s how it works: With your face numbed by either cream or a local anesthetic, a hypodermic needle is inserted underneath the skin, below the scar tissue, and run from side to side, beneath the surface of the skin. This breaks the connective tissue holding the scar to the undamaged skin below, encouraging the skin to regenerate, and eventually promote new collagen growth, which lifts that depression in the skin causing the scar. For me, there was never a sweeter sound than the “Pop! Pop! Pop!” that accompanied the inserted needle breaking up the fibrous bands, which had been pulling down my skin and creating the scars I longed to erase.


    Subcision works best with rolling scars, but there are also other factors, like age, that come into play. “With subcision, I don't find the age of the scar is as important as the age of the patient,” says Adam Mamelak, MD, a board-certified dermatologist in Austin, Texas. “Older patients do not have the same ability to regenerate collagen as younger patients.” 

    In my case, I was 34 when I began a series of acne-scar subcisions — spaced six weeks apart, at roughly $500 a treatment. After several months — almost half a dozen treatments — my pitted cheeks filled in. (While there’s no hard-and-fast data, dermatologists typically report improvements anywhere from 40 to 90%, based on patient feedback.)

    It’s not to say my skin was perfect afterward. Subcision will not work on other scars — those of the icepick variety — but in those cases, lasers can actually have some benefit. But even with those few scars lingering, having done away with the majority of those self-esteem-destroying depressions in my skin, I am one giddy acne survivor.

    And I no longer fear the light.

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    Skin microneedling plus platelet-rich plasma versus skin microneedling alone in the treatment of atrophic post acne scars: a split face comparative study

    Pages 281-286 | Received 02 Jun 2017, Accepted 24 Jul 2017, Accepted author version posted online: 07 Aug 2017, Published online: 26 Sep 2017
    Abstract

    Introduction: Acne scarring is a permanent disfiguring sequel, which can take varied morphological forms. Many therapeutic measures have been performed to improve acne scarring such as microneedling. Our objective is to evaluate the efficacy and safety of microneedling alone versus microneedling combined with platelet rich plasma in the treatment of post acne.

    Methods: The study included 35 patients with mild to severe post acne atrophic scar. All the patients received four sequential treatments of skin microneedling alone on the right side of the face and skin microneedling followed by topical application of platelet rich plasma (PRP) on the left side of the face with an interval of 3 weeks. Two blinded dermatologists evaluated the clinical response according to qualitative global acne scarring system grading of Goodman & Baron. Patients are queried about their satisfaction with the treatment outcomes.

    Results: The study included 35 patients with a mean age of 24.7 ± 6.8 years. There was a significant improvement in the degree of scar severity before and after treatment on both the sides. Regarding patient’s satisfaction grades, there was a significant improvement after both treatment modalities with insignificant differences between both treatment modalities.

    Conclusions: Both microneedling and microneedling in combined with PRP showed satisfactory results.

    Keywords: MicroneedlingPRPscar
    ________________________________________________________
     
     
     
    High-frequency electrosurgery in ice-pick scars: pre and post treatment comparative study
    Carlos Roberto Antonio - Head of the Department of Dermatologic Surgery and Instructor, Faculdade de Medicina de São José do Rio Preto (Famerp) - São Josá do Rio Preto (SP), Brazil
     
    ABSTRACT Introduction: Acne scars result from inflammation of acne vulgaris and are a frequent cause of complaints in dermatology practices. Atrophic scars are the most common, and may be classified into superficial, medium, and deep. There are several treatment options for deep atrophic scars, however they have limited efficacy in general, undesirable side effects and are expensive. Objective: To evaluate the treatment of deep atrophic scars with high frequency electrosurgery.
     
    Methods: Ten patients with deep atrophic acne scars received 3 high frequency electrosurgery treatment sessions with intervals of 1 month. The following were used to evaluate the outcome 1 month after the last session: histological aspects of selected scars as compared to the baseline; ratings attributed to the results by the patients (worsened, unchanged or improved); and standardized photographs at baseline and 1 month after the last session performed by a physician not related to the study, who also rated the results (worsened, unchanged or improved).
     
    Results: Histological analysis evidenced a reduction in local fibrosis. All patients noticed improvement in the lesions. The evaluator dermatologist physician verified the presence of clinical improvement in all patients.
     
    Conclusion: High frequency electrosurgery is a straightforward, inexpensive and effective method for the treatment of atrophic deep acne scars.
    2018-12-26_8-04-04.jpg2018-12-26_8-04-41.jpg
     
     
    INTRODUCTION Acne is a common condition that affects roughly 80% of adolescents,1 and permanent scars may arise as a result of the inflammatory process that occurs in acne vulgaris, 2 affecting up to 95% of acne patients. Their cause is associated with both the severity of the underlying condition and the delay in beginning the treatment.3 Depressed atrophic scars are classified as non-distensible (superficial, medium and deep) and distensible.4 This is the most common type of scar, which occurs due to the action of inflammatory mediators and enzymatic degradation of collagen fibers and subcutaneous fat, resulting in lesions that often have a whitish background caused by deep fibrosis.5 According to the depth of the damage, atrophic non-distensible scars can be superficial, medium or deep, the latter being known as ice picks (up to 1mm in diameter) or dystrophic (above 1mm). They compromise the dermis in its full extension, reaching the subcutaneous. The various treatment options for this type of scar include chemical peeling, dermabrasion, ablative and non-ablative fractional lasers, punch excision, grafts, subcision, and combined methods, nevertheless these methods are generally associated with limited effectiveness, undesirable side effects and high costs.1 The search for treatment for acne scars is a frequent cause of consultation with Dermatologists since there is a negative impact on the affected patient’s quality of life.6 It is known that acne scars are associated with frustration, sadness and anxiety, and might even constitute a risk factor for suicide.7 In light of those facts and in order to find a new treatment option for atrophic and deep acne scars, the authors of the present article evaluated the use of high frequency electrosurgery (HFES) applied with a needle punctually to the scar, in order to promote immediate retraction and decrease of local fibrosis. The method is simple, cost effective, and easy to apply, yielding positive results by destroying the scar, decreasing its diameter and stimulating local tissue regeneration.
     
    METHODS A prospective, non-randomized study was carried out with 10 patients from the Dermatologic Surgery Ambulatory of the Facudade de Medicina de São José do Rio Preto (Famerp) clinically diagnosed with deep atrophic acne scars (Figure 1). The selected patients did not bear active acne, with some bearing Grade I lesions only. Higher-grade acne lesions were excluded from the selection. The patients were not receiving any type of treatment for scars and were in use of sunscreen. For the control of facial oiliness, only soap was used. The selected patients received HFES treatment performed with the assistance of a fine tip in the shape of a needle. The application was carried out with a Wavetronic® device (Loktal, São Paulo, Brazil) in a way that the needle-shaped tip or a 30G needle (13 x 0.3mm) was placed in the center of the atrophic scar, exerting pressure on the skin, with the 5W electric current being subsequently activated, with the device set at the mode. Immediately after the electrical discharge, the scar underwent retraction, elevation and whitening (Figures 4 and 5). Three sessions were performed in each patient at onemonth intervals. The evaluation methods employed were: i) biopsies of selected scars for anatomopathological study, before and one month after the last session; ii) subjective evaluation of the patients’ opinion (outcomes received one of the following ratings: worsening, absence of improvement or improvement of the lesions); and iii) evaluation of standardized photographs before and one month after the last session. A physician not related to the study evaluated the images, also attributing the ratings worsening, absence of improvement or improvement to the lesions. 
     
    RESULTS The objective analysis of the photographs, performed by a dermatologist physician not related to the study, attributed the rating improvement to the scars of all participants. Reduction of local fibrosis and scar elevation were observed after the procedure (Figure 6). In addition, in the subjective evaluation carried out by the patients, all participants attributed the rating improvement of the lesion to the final outcomes. After the electrosurgery session, mild local erythemas emerged, with the subsequent formation of a discrete crust on the scar that resolved within 7 to 9 days after the procedure. The patients were instructed not to manipulate the crusts and to use sunscreen in the lesion’s location. In the anatomopathological study of the biopsies performed before the procedure, fibrosis and perivascular and periadnexal lymphocytic inflammatory infiltrate were observed in the upper and middle dermis (Figure 7). It was possible to observe only epidermal atrophy in the biopsy performed one month after the last treatment session, with the dermis remaining unaltered, with absence of fibrosis and inflammatory infiltrate.
     
    DISCUSSION For being a simple and traditional procedure, HFES has been used to treat several skin conditions for more than 50 years, having become part of the routine of most dermatologist physicians. It acts by means of a high-frequency electromagnetic wave, which is transformed into heat due to local resistance when penetrating the tissues, resulting in the boiling of the intracellular water, causing the rupture of the cell due to an increase in its internal pressure, in turn generating tissue clotting and coagulation.4,8,9 As a result, when HFES is applied to atrophic and deep acne scars, destruction of local fibrosis and consequent tissue remodeling takes place, which can be seen in the biopsies performed after the procedure. There are other options, simpler and less expensive than laser therapy, for treating atrophic scars, however they may be associated with some undesirable side effects. The CROSS technique (Chemical Reconstruction of Skin Scars) consists in the spot application of trichloroacetic acid on atrophic scars in order to stimulate neocollagenesis. However, this technique may be associated with adverse events such as hypopigmentation, hyperpigmentation and formation of residual scars on normal skin around the initial scar. 10,11 The technique that employs full thickness skin micrografts performed with minipunchs consists of the excision of the atrophic scars using punchs, followed by the implantation of micrografts at the site of excision. The scar is removed and replaced by a slightly larger skin graft, usually harvested from the postauricular area. Some grafts will level with the skin’s surface; others will remain elevated, meaning that a new therapeutic intervention is often necessary to achieve leveling. The application of HFES with the needle-shaped tip allows that the electrosurgery’s action be restricted to the site of fibrosis, avoiding possible complications secondary to the application in the healthy skin around the lesion. Also, it provides enhanced safety in higher phototypes. In this manner, the present study allowed the observation of a new, straightforward and cost effective option for efficaciously treating acne scars, which is one of the major causes of consultations to dermatologist physicians.
     
    CONCLUSION Based on the reported cases, HFES was proven effective and safe in the treatment of atrophic and deep acne scars. As a result, it emerges as a more accessible treatment option for both patients and physicians, since it employs a technology that is widely used in dermatology practices and can contribute to the treatment of an important complaint that has a considerable psychosocial impact.

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    All very useful information in one place, thank you BA. 

    Cannula Subcision.. I asked this question Pr.Chu and he said that Cannula won’t cut the tethers. May be it is in my case only..

    So study sais one thing, the one of the best doc in the world sais differently...when you talk to any doc it is very difficult to object because the study said different..and because the choice of the scars doctors is sooo limited you do not want to go away just because his opinion is different to the study...

    Saw these pics long time ago, some of the pics provided were done in a slight different angle and lightwhich could change how the skin looks. Figure 5 for ex. Yes the healing, painfully sloow... 

    All in all just proves how difficult problem is acne scars and this is the life long condition we have to live with(

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    Restylane stimulates collagen production

    Apr 1, 2007

    By: Bob Roehr

    Dermatology Times

     

    National report — The dermal filler Restylane (Medicis Aesthetics) appears to stimulate production of collagen in aging and photodamaged skin, according to a study published in the February issue of the Archives of Dermatology.

     

    Senior investigator John J. Voorhees, M.D., tells Dermatology Times the mechanical stretching of the fibroblast appears to stimulate the genes of fibroblasts to produce more collagen and to decrease production of collagenase, the enzyme that degrades collagen. But stretching may not be the entire explanation.

     

    With age, fibroblasts produce less collagen and more collagenase, and thus starts a downward spiral that reinforces itself. The dermis becomes littered with broken collagen and the skin loses firmness, Dr. Voorhees says.

     

    Much of this association has been known for some time, but the causation and mechanisms were not, says Dr. Voorhees, the Duncan O. and Ella M. Poth Distinguished Professor of Dermatology and chair at the University of Michigan Medical School, Ann Arbor, Mich.

     

    Fibroblast role

    "Over the last five years we have shown that a fundamental problem in aging skin, as well as photoaging, is that the collagen becomes increasingly broken up.

     

    "We realized the importance of this when we took the fibroblasts out of photoaged skin and put them on nonbroken collagen. They made just as much collagen as fibroblasts from photoprotected skin. So, basically, the fibroblast is okay, it is not just a problem of photoaging."

     

    Dr. Voorhees hypothesizes, "If we could restretch the collapsed fibroblast and make it look like a young fibroblast, maybe it would reacquire the functional activity of the photoprotected fibroblasts, i.e., the production of more collagen. And that is exactly what happened.

     

    "Everybody thought that fillers work by virtue of their physical presence, filling in holes, nooks and crannies. I don't doubt that is true for a few weeks" before the filler is degraded and absorbed, he says.

     

    However, in a pilot study that is included in the Materials and Methods section of the study, four of six subjects showed an increase in pro-collagen messenger RNA at one week.

     

    "The hyaluronic acid filler is absorbed; it got smaller and smaller over time. Then the collagen is likely to take over and dominate the clinical effect," Dr. Voorhees says.

    In vitro work has established that stretching a variety of cell types initiates a signal from the membrane to the nucleus and stimulates gene expression.

     

    "In this instance, we measured increased expression of genes for collagen, TIMP, and growth factor TGF-B. The stretch caused these things to happen," he says.

     

    Dr. Voorhees says researchers used Restylane because, at the time the study was planned, it was the only commercially available product with a long safety record. Medicis donated product for the trial but played no other role and "did not see the article until it was published," he says. Funding came from the department of dermatology Human Appearance Research Fund.

     

    Dr. Voorhees is cautious about extending these findings to other fillers and even to other formulations of hyaluronic acid. He does not have access to proprietary information on products, but assumes that differences in cross-linking "is probably the basis of their patents. You would expect that the different cross-linking would alter the biophysical properties of the cross-linked hyaluronic molecule into somewhat of a different shape.

     

    "That may influence the effect. We don't know if it is simply the stretch, or whether there is some interaction between the cross-linked hyaluronic acid and certain as-yet-unknown receptors on the fibroblast surface. Until that work is done, the answer is unknown."

     

    Dr. Voorhees would like to see a head-to-head trial of numerous fillers to help answer those questions, but he doubts that will ever take place.

     

    He also is curious to see how durable these effects are.

    "We would like to take it out to a year and see where between 13 weeks and a year it falls off, or maybe it goes on longer than that," he says.

     

    He says, "We did this work in the context of aging because that is the work that we do. But it should be applicable to any defect in the skin—scarring, acne scarring, HIV-associated wasting, burn scars, wound healing."

     

    Fillers seldom have been used with wound healing because it was thought that the product would simply be broken down and absorbed by the body and, therefore, wasn't worth the effort and expense. But with this new information, he expects that others will begin to reconsider the use of fillers in wound healing.

     

    Better understanding

    Dr. Voorhees continues to search for the intracellular signaling molecules that regulate the expression of these genes.

     

    A better understanding of that process is important to both the problems of underexpression of collagen associated with aging and those of overexpression associated with fibrotic diseases such as scleroderma, scars, keloids and burn scars.

     

    "This is the type of study that we've needed for a long time," says Seth L. Matarasso, M.D., a private practitioner and clinical professor of dermatology at the University of California, San Francisco. "It shouldn't surprise anyone who has worked with Restylane, which has a lion's share of the marketplace.

     

    "In the literature and anecdotally, we see an effect that lasts for four to five months. And the next time you use it, there is tissue memory; you don't need to do it as frequently and you don't need to use as much."

     

    He says other fillers often contain saline and an anesthetic that are quickly absorbed. "I don't think there is an in situ residence that is large enough and long enough to stimulate a response," he says.

     

    "Clinically, you can't just make the transition from collagen to Restylane injections," as the techniques of how to use them are different, Dr. Matarasso says.

    The clinician has to modify the depth and pattern of the injections and take the memory effect of the product into account with subsequent injections.

    ____________________________________________________________________________

    Filler Longevity.

    Regarding Filler - Sculptra (HA filler has a quicker response due to instant volumizing ability and sbsorpton of water by the filler over a week or two - swelling also makes things look different, wait 2 weeks to see results; Sculptra is for widespread scarring across the face, it stimulates collagen especially when used with rf microneedling):

    "Sculptra's full effect takes about 6 weeks to fully appreciate. It will take about 6 weeks to get the effects of collagen building.  There are some subtle changes over the next 7 mos or so, but not much volumizing effect.  If you are too full, you just have to wait it out and let the effects gradually diminish over then next couple years.  It is extremely important to choose the right doctor for these long lasting fillers.  "

    -Dr Steven Weiner

    HA Filler Longevity

    ( High movement areas go quickest (lips, mouth, forehead, smile lines, eyes), the body's absorption of the filler, body builders do this quite quickly, botox helps the filler's longevity, repeated injections of HA can lead to possible permanent results or less frequent injections needed, subcision's results are permanent (filler just acts as a spacer) -



    "There is no set timeline on how long a filler lasts. It all depends on how much is injected and the areas that are injected. If you put a very small (or too small) amount in, you won't get a good result and it will last a very short time.

    What I see in most of these cases where people say it 'didn't last' is that they only had a small budget for fillers and wanted too many areas injected at the same time (amount paid for does not equal results patient sought). If I have a patient with unrealistic expectations, I tell them to either do one area alone or, if necessary, save up to do more of a filler in the future so that the area is done in the right way.

    Lastly, the skill of the injector is very important here. There are many new injectors who simply don't know what they are doing and how to do it. This means that they are injecting fillers in the wrong place and that can often result in very short length of activity.

    It is so very important to go to a dermatologist or plastic surgeon who actually does their own injections. While they may have 'staff' who do injections reasonably well, the only way they are going to get skills that translate to good injections is to do it themselves and not pawn it off to someone." (A expert injector - nurse who does this full time is also acceptable).
     - Joel Schlessinger, MD 


    " Depending on the facial area, Restylane can last approximately 3 to 6 months. There is no guaranteed time line, and fillers tend to last the longest in areas that are less mobile - typically, 3 months for the lips, 6 months under the eyes and cheek.
    While traces of Restylane may be found in the body up to 12 months, the full cosmetic benefits start to decrease 3 to 6 months, depending on the area treated. In my office, I have noticed that after the third injection, the intervals tend to be longer and the body builds up collagen in those areas on it's own. Voluma or Lyft lasts longer than Restylane but is more costly. 
    There are fillers, such as Perlane and Bellafill that last longer (permanent). If you've fallen in love with your results and want to commit to a longer time line, discuss a longer lasting product with your plastic surgeon."
    - David C. Mabrie, MD, FACS 

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    Botulinum toxin injections may improve scarring

      Acne%20scars%20%28%C2%A9BudimirJevtic%2C

       Long lauded for its ability to reduce the appearance of wrinkles, botulinum toxin is now being considered for reducing scarring. (©BudimirJevtic,AdobeStock,55216160)

      by: Nadia M. Whitehead

       

      Long lauded for its ability to reduce the appearance of wrinkles, botulinum toxin is now being considered for reducing scarring.

      By using botulinum toxin to denervate underlying muscle and immobilize tension―which increases inflammation, fibrosis, erythema and scar size―scarring can potentially be reduced, say researchers writing in a review published in the Journal of Drugs in Dermatology.

      The review, published in the September issue of the journal, highlights several success stories of the toxin’s use in improving scarring. Dr. Domenico Vitarella, Ph.D., author of the review and a researcher with Bonti, Inc., says that although the FDA has not approved botulinum toxin for this specific use, “the treatment seems to be gaining momentum among physicians.”

      In 2006, researchers reported the first blinded, placebo-controlled, randomized study for scar reduction on 31 patients with forehead wounds. The patients either had traumatic forehead lacerations or were undergoing plastic surgery for the removal of a mass on the forehead.

      Patients received a botulinum toxin or placebo injection in the musculature adjacent to their lesions within 24 hours of surgery. Afterwards, those who received the botulinum toxin received a median Visual Analog Scar Score (VASS) of 8.9 while placebo recipients received a median score of 7.2. 

      A separate study reported in 2013 described 24 patients with facial wounds who were randomized to receive no injection or the injection of botulinum toxin within 72 hours of surgery. At one-year follow-up, the group treated with botulinum received a media Vancover Scare Scale (VSS) score of 8.25, while the control group received median scores of 6.35.

      In his review, Dr. Vitarella writes that despite these successes, much remains to be explored. For one, larger clinical trials are still needed to gain FDA approval.

      “Physicians are experimenting and using this product off-label for scar reduction [right now,]” Dr. Vitarella says. “Bonti believes this is a great area of study and this can work and help [reduce scarring], but we are not able to advocate for physicians doing this until there’s official FDA approval.”

      Optimal dosing remains to be determined as well so as to not cause patients functional problems, particularly when botulinum is applied to the lower face to make sure the mouth functions properly (any expert injector can figure this out from experience). 


      REFERENCES

      Akash Dhawan, Sunil Dhawan MD, Domenico Vitarella PhD. "The Potential Role of Botulinum Toxin in Improving Superficial Cutaneous Scarring: A Review," the Journal of Drugs in Dermatology. September 2018.

      Holger G. Gassner MD, Anthony E. Brissett MD, Clark C. Otley, MD, et al. "Botulinum Toxin to Improve Facial Wound Healing: A Prospective, Blinded, Placebo-Controlled Study," Mayo Clinic Proceedings. August 2006. DOI:https://doi.org/10.4065/81.8.1023

      Makram Ziade, Sophie Domergue, Dominique Batifol, et al. "Use of botulinum toxin type A to improve treatment of facial wounds: A prospective randomised study," JPRAS, February 2013. DOI: https://doi.org/10.1016/j.bjps.2012.09.012

      Holger G. Gassner, MD; David A. Sherris, MD; Oren Friedman, MD. "Botulinum Toxin–Induced Immobilization of Lower Facial Wounds," JAMA Facial Plastic Surgery. March/April 2009. DOI:10.1001/archfacial.2009.3

       

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      This article (see below) validates all of the advice I have given over many years now. Dr Steven Wiener - top 1% of acne scar Drs in the USA (Panama, Florida) is Friends with Dr Lim. I agree with many points in the below article which has case studies, split blinds, and research papers to back it up. The only things I do not agree with after helping thousands of patients with acne scars are:

      1) healing time, many are sensitive and do not realize that collagen is extremely slow to build and takes up to 3-6 months to build, as such many Dr's treat weekly or monthly and do not allow proper healing time (this gives them quicker $$,$$$), but can cause side effects in some patients or results to not occur as the body heals naturally. You take charge of your treatment time and book with them or tell them you will book when you find out your schedule. If it's a area that has never been treated, sure it can be treated soon. Subcision and tca cross can be done together in a a session, I would not combine laser and a bunch of other procedures - space things out. Even a gentle Fraxel treatment can take 6 months to heal from under the skin (the surface epidermis shows no signs). 

      2) I am strongly against Bellafill. Dr Weiner is a advocate for this filler and paid to promote it. Permanent is permanent. Yes it's FDA approved, so are many other harmful or permanent things. There are side effects. Unlike a HA filler you can't just reverse it and need to cut it out. Why is it banned in some countries as harmful with a history of bad side effects (called "PMMA"). The problems occur in my experience after 5 years time. With the beginning it looking great and the patient happy. As we age our skin sags (thus it may not be in the same spot in years to come, and can migrate). IT can cause infection and grandulomas bumps in those who are sensitive as a surface for bacteria on the fiberglass balls. It's very very expensive and needs many sessions to reach the enjoyed volume. It's not something to go into a clinic and say I want Bellafill to save a few bucks because it's permanent. No, try HA filler and see if you even like the look, ... so many don't like the filler afterwards, why make this permanent. Like what your going to have done conservatively. IF you do goto Dr Wiener only get HA filler first, then the choice is yours.  I find much better results with Sculptra for widespread (many) scarring as a layer under all your scars as a foundation before doing lasers and other devices, you get the HA filler done latter to the individual pits. Dr Wiener will not use this product on Acne Scar patients, so just go get your filler done elsewhere by any expert injector before you do more treatments with him, if you want Sculptra (he makes more $$$$$ off Bellafill). Sculptra is also long lasting, and a bio-simulator (collagen) but has a better track record in fat deficiency, it's even used on HIV patients for this cause - stimulate collagen and only lasts a few 3-6 years, not permanently. If all you can afford is one treatment of Sculpta a year tell the Dr this and do it once a year, if you can afford a full course then you get quicker benefits. For those who are low on cash do Chinese Cupping (Amazon) for their other sessions of subcision (remember most need 8 sessions), on the last sessions get HA filler to your individual pits injected. There will be longer lasting HA filler's that are reversible that come out in the future. You can stop filler at any time. We use it as a spacer (collagen growth) not permanently (if you want it done ongoing of have aging issues that is your choice). 

      Treatments for Lipoatrophy | ARTCTCSculptra® | Virginia Beach | Dr. Ben Hugo?u=https%3A%2F%2Ftse1.mm.bing.net%2Fth%3

      3 ) RF laser is not the cure for everything, ... Dr Lim as many know does other treatments with laser that no other practitioners will do. RF laser is great as a start but you might need something for textural scars (once you lift everything up), like low density co2 angled to the scars, J plasma, A deep peel for textural scars (Rullan is the best or find a plastic surgeon), or fully ablative erbium resurfacing. Treat the deepest issue, raise it and then worry about "textural issues." A Dr cannot be good at everything, you might have to goto one for one part of your treatment, and another for any other parts. It is in your best interest to consult (Even if you have to pay), a few aesthetic or cosmetic dermatologists and or plastic surgeons and pick the one(s) who will do what you need them to do as treatments are expensive and you want to be "sure". 

      4) Do Derminator or Dermastamping at home, we have a guide pinned to the top of the scar treatments sub, I think that is silly to say only Dr's can do this. This is a great at home treatment between every 3 months Dr's sessions (do microneedling monthly at home). Yes cleanliness is a issue as he mentioned, use new tips and don't put product on for 24-hrs after. Deep lengths are not needed only .75mm to 1.75mm depending on the area show's the best results, we don't want damage. If your sensitive or heal poorly, do not do this treatment you can cause more scars. You will know this by how you heal and the length it takes you. Most people are fine to do this at home. 

      5) PRP is for quicker healing, ... it does not show any other benefits to the scars. For those who use it as a filler the scars will re-attach, see filler mention above.Both can be done. 

      6) I do not agree with Genius being the only device that can treat someone with rf needling, ... I make no money saying this, Dr Wiener is marketing a product he is paid to be affiliated with. If you use another RF device or even the old Infini device is fine, ... not all Dr's can afford the newest thing. MAke sure the needles are insulated and your upper layers of skin will not be effected, most important point to all rf needling devices. Have them not turn up the power to the highest setting instead use lower to moderate settings, and don't have them go to deeply (mm) to avoid fat loss, we want to stay in the dermis (different for everyone). Have them pinch the skin, ... Dr Lim uses a cannula to determine depth of tissue by lifting it up and seeing how thin it is (if your skin is thin, you don't want to be going 2mm obviously! - make sure your practitioner is experienced not some crackpot or assistant that uses the same setting - ask ahead of time how many they have done and if they do your skin type often). Again you need filler and subcision first or you could be hitting fat with enough fat loss - atrophy or some acne scar cases. We use Sculptra for widespread and rolling scars with fat loss, it is stimulated by the rf needling (after) to make more collagen (It must be done over dilute saline and injected throughout as a foundation layer under the scars  - never just in one spot like a HA filler (get this done on latter subcisions)!.  

      -- BA

      ___________________________________________________________________

      Acne Scar Treatment

      By Dr Steven Wiener

      Apri; 14th, 2019 

      Acne scarring has significant debilitating effects on one’s overall self-worth and confidence. Millions in the US are affected. There have been improvements in techniques and energy devices in past few years which have led to better outcomes for acne scar treatments.

      Subcision – This is process of breaking up deeply tethered scar bands associated mainly with atrophic/rolling scars. Subcision has be performed for acne scars for decades and just using this procedure alone has proven to lead to significant acne scar improvements. Recently there have been a couple publications suggesting that cannula subcision had better outcomes, less downtime, and less discomfort than the traditional method of using a Nokor needle. A cannula has a blunt tip so it is also safer – less chance for cutting a nerve or blood vessel than the knife-like edge of the Nokor needle. In the study, both patients and the performing doctor rated the results better when using the cannula. Subcision is particularly important, in Dr. Weiner’s opinion, to be performed prior to any energy device for tethered scars. This is based on the fact that RF and laser will preferentially travel through collagen – which is high is water content – than fat or most other tissue. Scars are predominantly collagen, so it makes sense to cut the connection of the scar to the deeper tissue. Through personal communication with Dr. Davin Lim, biopsies he performed have shown scar band that reach the deeper fat pads from tethered acne scars. Transmission of the energy through the scar can theoretical lead to collagen contraction and deepening of the tethered scar. Sometimes fillers are placed at the time of the subcision to improve the volume loss associated with the scarring. Some hypothesize that putting a “spacer of filler” might improve results as well. Dilute lidocaine during the initial passes allows for this procedure to be well tolerated.

      TCA CROSS – TCA (Trichloroacetic Acid) is a chemical peel used to improved acne scarring by placing minute quantities in the scar using a toothpick. CROSS stands for Chemical Reconstruction of Skin Scars. The most common use of this procedure is for ice pick and small boxcar scars. The process of causing a controlled chemical burn, allows for the body to heal from the deepest part of the scar towards the skin surface. This makes the scar smaller in diameter and shallower. Usually a series of 3-6 treatments are needed, with 3-4 weeks between treatments. There will be some mild scabbing for a few days which needs to be kept moistened for best results. Risk include widening of the scar or post inflammatory hyperpigmentation (PIH).

      Radiofrequency Microneedling – This technology (RFM) has been available in the US for about 6 years and has revolutionized acne scar treatment. Using needles which are insulated, energy is delivered into the scar tissue directly and bypassing the epidermis, for the most part. The insulation protects the skin surface from heating so darker skin type individuals are at much less risk of PIH (post inflammatory hyperpigmentation) vs a laser treatment. The needles allow for deeper penetration than lasers as well. Overall, downtime is less than ablative lasers in most individuals (when insulated needles, proper technique, and appropriate settings are used). With acne scarring affecting darker skin types disproportionately, this is an excellent alternative to lasers. The Genius has recently been FDA approved and is now the “best of bread” RF microneedling device. There is now impedance feedback from the needles which allows for improved and exact energy delivery. The resistance in the tissues being treated is measured and this is important because throughout one’s face, there are differences, as well as between different individuals. Also, as tissue are heated or subcised, the resistance changes. Prior to Genius, there was no idea of how much energy was being delivered. There is now an accurate total energy for each pulse and a cumulative total. Other improvements include needle design-sharper, stronger motor, and feedback regarding quality of each pulse fired.

      There is a myth that needs to be busted. Deeper does not mean better for acne scars.

      The needles must stay within the scar for best results. If the needles go beneath the dermis, there is a risk for heating the fat and fat loss. Let it be known that the actual depth of the needles in most RFM devices is less than the settings, and becomes less accurate, the deeper the settings are. There is inherent resistance of the skin to penetration and many needles aren’t sharp enough or motors aren’t strong enough to get to the desired levels in the time required. This has also been addressed with the Genius and it’s depths are very accurate after extensive testing.

      In addition, higher energy levels on any device which doesn’t monitor impedance, can actually result in very little energy delivered. Once the tissue is heating beyond a critical level, the resistance becomes so high that energy output cuts off. However, when higher energy levels are desired when using the Genius, the energy is adjusted to the increasing impedance and it is successfully delivered.

      Fillers – Fillers are a very integral part of improving acne scars. They are extremely useful for the atrophic scars and the lipoatrophy associated with these scars. The aging process leads to dermal thinning and fat atrophy, which makes the acne scars appear worse, even if active acne has long been controlled. Fillers need to be injected deeply for correcting large areas of volume loss and superficially in minute quantities for focal defects. A hyaluronic acid filler will give about 12 months of improvement vs Bellafill which can give near permanent improvements. Bellafill does require a skin test to see if one has a allergy to the bovine collagen (0.5% chance) which needs 3-4 weeks to determine. There is some who feel fillers in areas of subcision will prevent re-adhesion of the scars. Most failures from other treatments are related to not recognizing the need to fillers to improve the acne scars.

      Lasers – Erbium/CO2 ablative lasers still are beneficial for acne scars but have more downtime and risks vs RFM. Deeper skin imperfections are not improved with lasers and require fillers. These devices are best reserved for more superficial scars, mainly boxcar scars. Non ablative lasers are less affective but safer and in the author’s opinion give very minor results.

      Microneedling – Also know as “Collagen Induction Therapy” CIT, has become popular in recent years. There are rollers available for home use and then there are medical grade devices which go to depths of 2mm or deeper and create thousands of penetrations per second. Rollers should be not be used at home for 2 reasons – questionable sterility at home and they tear tissue more than the in-office devices. Often these treatments are combined with topicals and PRP. It is highly recommended to not use any products on the skin which would normal not be injected. There have been many cases of infection and granulomas from these practices. Even when done in the office with PRP or amniotic membrane products, the efficacy of this procedure is minimal, and should be reserved for only mild acne scarring.

      PRP/Amniotic membrane products – There is some date to support that better results and faster recovery with less side effects if PRP or amniotic membrane products are used during acne scar treatments. There is a movement more towards amniotic/placental products and away from PRP because there are more growth factors/healing properties in these vs PRP.

      LLLT – There is a plethora of studies to suggest that using low level laser light (LLLT) is beneficial to results and healing times. The most researched device is Healite, and this should be performed immediately following all acne scar procedures which use energy devices. It calms the skin and improves circulation.

      Acne scarring procedures are continuing to improve as technology and techniques evolve. One must understand that results require months to fully appreciate and multiple treatments (3-5 or more) are often needed to optimize results. Expectations need to discussed with providers/patients so that all are on the same page as to what one can achieve with treatments.

      Dr. Weiner is an Acne Scar Center of Excellence designated by Bellafill and is a specialist on acne scars. He is a lecturer and trainer for Bellafill. He has become one of the leading authorities on Radiofrequency Microneedling and travels the globe lecturing on this technology. He performed the FDA trails for the Genius. He recently authored a chapter on RF Microneedling which soon will be published in the Facial Plastic Clinics of North America. He also wrote a recent chapter on Radiofrequency Safety and Complications which will be part of a book titled “Complications in Minimally Invasive Facial Rejuvenation: Avoidance and Management” by Paul Carniol, MD

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